ER 


Kt 


Lt'< 


_„<..-rv   Of 


f)UBUC 


HEAV-TH 


UB^^ 


The  PjLiblic  Health 
Movement 


PHILADELPHIA 

American  Academy  of  Political  and  Social  Science 

1911 


Copyright,  191 1,  by 

The  American  Academy  of  Political  and  Social  Science. 

All  rights  reserved. 


CONTENTS 


PART  I 

THE  GENERAL  PROBLEM 

PAGE 

HEALTH  NEEDS  AND  CIVIC  ACTION 3 

William    H.    Allen,    Pli.D.,    Director,    Bureau    of    Municipal 
Research,  New  York. 

HOUSING  AND  HEALTH    13 

Lawrence   Veiller,   Secretary,   National   Housing   Association, 
New  York. 

SCIENTIFIC  RESEARCH  BY  THE  PUBLIC  HEALTH  SERVICE..       26 
J.  W.  Kerr,  M.D.,  Bureau  of  Public  Health  and  Marine-Hospital 
Service,  Washington,  D.  C. 

THE  CENSUS  AND  THE  PUBLIC  HEALTH  MOVEMENT 42 

Cressy  L.  Wilbur,  Chief  Statistician  of  Vital  Statistics,  Bureau 
of  the  Census,  Washington,  D.  C. 

SOURCES     OF    INFORMATION    UPON    THE    PUBLIC    HEALTH 

MOVEMENT    61 

Robert  Emmet  Chaddock,  Ph.D.,  Assistant  Professor  of  Eco- 
nomics,  University   of  Pennsylvania. 

WORK  OF  THE  COMMITTEE  OF  ONE  HUNDRED  ON  NATIONAL 

HEALTH     77 

Wm.  Jay  Schieffelin,  Ph.D.,  Chairman  of  the  Executive  Com- 
mittee of  Committee  of  One  Hundred  on  National  Health. 

PUBLIC  HEALTH  MOVEMENT  ON  THE  PACIFIC  COAST 87 

Sarah  I.  Shuey,  M.D.,  Oakland,  Cal. 

PROTECTING  PUBLIC   HEALTH   IN  PENNSYLVANIA    95 

Samuel  G.  Dixon,  M.D.,  LL.D.  Commissioner  of  Health,  Com- 
monwealth of  Pennsylvania. 

HEALTH  PROBLEMS   OF  THE  INDIANS    103 

Joseph   A.   Murphy,    M.D.,   Medical   Supervisor,   United  States 
Indian  Service. 

HEALTH  PROBLEMS  OF  THE  NEGROES  110 

John  A.  Kenney,  M.D.,  Tuskegee  Institute,  Alabama. 


235507 


iv  Contents 

PART  II 

DISEASE  CARRIERS -THE  CONTROL  OF  CAUSES 

PAGE 

;  THE  RURAL  HEALTH  MOVEMENT  123 

Ch.  Warden  Stiles,  Ph.D.,  Professor  of  Zoology,  United  States 
Public  Health  and  Marine-Hospital  Service. 

SANITATION  IN  RURAL  COMMUNITIES    127 

Charles  E.  North,  M.D.,  New  York. 

TROPICAL  DISEASES  AND  HEALTH  IN  THE  UNITED  STATES     150 
John   M.  Swan,  M.D.,  Medical  Director  of  The  Glen  Springs; 
Secretary   of  the  American   Society   of   Tropical   Medicine, 
Watkins,  N.  Y. 

THE  HOUSE  FLY  AS  A  CARRIER  OF  DISEASE    168 

Edward     Hatch,     Jr.,     Chairman,     Fly    Fighting    Committee, 
American  Civic  Association,  New  York. 

THE   MOSQUITO    CAMPAIGN   AS   A   SANITARY   MEASURE    180 

John   B.  Smith,  Sc.D.,  State  Entomologist  of  New  Jersey. 

CLEAN   MILK   AND   PUBLIC    HEALTH    192 

Jesse  D.  Burks,  Ph.D.,  Director,  Bureau  of  Municipal  Research 
of  Philadelphia. 

VENTILATION   AND    PUBLIC    HEALTH    207 

D.   D.   Kimball,  of  Richard  D.  Kimball  Company,  Mechanical 
and  Electrical  Engineers,  New  York. 


PART  III 


ELIMINATION  OF  DISEASES— PHYSICAL  CARE  OF 
INDIVIDUALS 

SOCIAL    SERVICE    WORK    IN    HOSPITALS 223 

Richard  C.  Cabot,   M.D.,  Boston,  Mass. 

MOUTH   HYGIENE  AND  ITS   RELATION  TO  HEALTH    228 

Arthur  H.  Merritt,  D.D.S.,  New  York. 

THE    PHYSICAL   CARE    OF    CHILDREN    243 

Walter  S.  Cornell,  M.D.,  Neurologist  to  the  Division  of  School 
Inspection,  Department  of  Public  Health  and  Charities, 
Philadelphia. 

WHAT  AMERICAN  CITIES  ARE  DOING  FOR  THE  HEALTH  OF 

SCHOOL    CHILDREN    250 

Leonard  P.  Ayres,  Russell  Sage  Foundation,  New  York. 


Contents 


PAGE 

THE  ELIMINATION  OF  FEEBLE-MINDEDNESS 261 

Henry  Herbert  Goddard,  Ph.D.,  The  Training  School,  Vine- 
land,  N.  J. 

PREVENTION   OF   INFANTILE   BLINDNESS    273 

Charles  F.  F.  Campbell,  General  Secretary,  Pennsylvania  Asso- 
ciation for  the  Blind;  Editor,  "Outlook  for  the  Blind," 
Pittsburg,  Pa. 

THE  WARFARE   AGAINST   INFANT   MORTALITY    288 

S.  W.  Newmayer,  M.D.,  in  charge  of  Child  Hygiene,  Depart- 
ment of  Public  Healtt  and  Charities,  Philadelphia. 


PART  ONE 


The  General  Problem 


(I) 


HEALTH   NEEDS   AND   CIVIC   ACTION 


By  William  H.  Allen,  Ph.D., 
Director  Bureau  of  Municipal  Research,  New  York  City. 


Of  $ii2,cxx),ooo  requested  last  year  in  4400  appeals  to  one 
New  York  philanthropist,  $1,075,000  was  asked  for  various  co- 
operative health  purposes.  Of  this  total,  only  $45,000,  or  less 
than  one-half  of  one  per  cent.^  was  asked  for  preventive  or  edu- 
cational health  work.  The  rest  was  for  hospitals,  dispensaries, 
clinics,  etc. 

Of  $163,000,000  in  public  benefactions  last  year,  $19,100,000 
was  for  health  purposes.  Of  this  not  one  dollar  was  for  teaching 
laymen  or  governmental  officials  how  to  use  knowledge  already 
possessed,  while  $6,800,000  was  for  finding  facts  not  yet  known 
about  cancer,  hookworm,  etc.,  and  $12,200,000  for  hospitals  and 
medical  colleges. 

When  John  S.  Kennedy's  will  provided  for  public  benefac- 
tions of  $32,000,000,  not  one  dollar  was  given  in  a  way  that 
indicated  an  interest  in  preventive  health  work,  or  in  what  we 
speak  of  as  the  "health  movement."  The  only  part  of  his  gift 
of  which  he  could  have  been  certain  that  any  fraction  would  be 
applied  to  preventive  and  educational  health  measures  was  the 
$750,000  for  the  New  York  School  of  Philanthropy,  where  in  the 
treatment  of  social  and  civic  subjects,  considerations  of  private 
and  public  health  are  given  emphasis. 

Among  the  world-famous  gifts  of  Mr.  Rockefeller  and  Mr. 
Carnegie,  which  together  total  nearly  $350,000,000,  not  one  dollar 
has  been  given  specifically  for  furthering  the  administrative  use 
of  health  knowledge  already  possessed,  whether  by  experts  or  by 
the  public,  and  less  than  $10,000,000  is  known  to  have  been  given 
for  hospitals  and  medical  research. 

What  does  it  mean  to  the  "health  movement"  that,  while 
hospitals  received  last  year  in  wills  and  in  large  gifts  over  $10,- 
000,000,  the  National  Committee  of  One  Hundred  could  not  raise 
$10,000  to  show  the  need  for  a  National  Bureau  of  Health? 

Is  it  not  really  true,  as  might  seem  from  the  figures,  that  rich 

(247) 


4     ** THe  Annals  of  the  American  Academy 

men  and  women  prefer  to  spend  their  money  on  curing  a  handful 
rather  than  on  protecting  a  townful,  or  on  training  a  few  medical 
students  rather  than  on  training  a  nation?  Is  a  not-yet-found 
germ  of  disease  more  alluring  to  a  philanthropist  than  a  not- 
yet-found  method  of  getting  communities  to  kill  the  infinitely  more 
important  and  more  famous  germs  already  understood,  and  to  apply 
for  all  of  us  the  lazvs  already  knoiini  to  the  favored  few?  No. 
They  give  from  misinformation,  not  from  choice. 

The  gap  between  what  we  know  and  what  we  get  done — 
between  obvious  opportunities  for  large  giving  and  the  actual 
large  giving  for  health  purposes — is  one  helpful  index  to  the 
present  status  of  the  "health  movement"  in  the  United  States. 
It  is  not  true,  as  one  is  apt  to  imagine  when  reading  a  list  of 
health  activities — of  beginnings  such  as  are  described  in  this 
volume — that  a  nation  has  been  won  over  to  a  full  appreciation 
of  its  health  problems.  True,  subjects  that  were  considered  im- 
possible for  use  in  the  magazines  and  newspapers  ten  years  ago 
are  given  prominent  places  with  profuse  illustrations.  True,  as 
the  physician  has  lost  his  monopoly  on  knoweldge  of  health  laws, 
the  layman  has  found  health  stories  and  health  work  absorbing. 
True,  our  bill-boards,  street  cars,  magazines  and  newspapers, 
aflford  innumerable  evidences  that  huge  factories  have  been  built 
and  stores  started  to  cater  to  the  new  appreciation  of  health  laws — 
e.  g.y  vacuum  cleaners,  incinerators,  sanitary  drinking  fountains, 
sanitary  underwear,  ventilated  shoe-soles,  disinfectants,  "spotless 
town"  soaps,  health  cereals,  etc.  Yet  we  are  barely  beginning, 
and  cannot  go  much  farther  without  giving  new  direction  to 
two  forms  of  private  benefaction:  (i)  money  gifts  by  rich  men 
and  women;  and  (2)  thought  gifts  by  those  who  most  influence 
private  giving  and  public  spending. 

If  private  giving  had  none  but  positive  influence,  we  could 
afford  to  disregard  it,  for  its  volume  is  small  when  compared  with 
health  work  done  through  taxes.  But  private  giving  has  also 
negative,  obstructive,  deflecting,  inhibiting  influences  on  those 
who  read  of  it.  In  fact,  its  thought  and  feeling  product  is  vastly 
more  significant  than  its  cure  or  relief  product.  For  example, 
when  John  D.  Rockefeller  said  to  the  world,  "There  will  never 
be  money  enough  to  do  the  world's  uplift  work,"  he  started  in 
motion   forces   and  doubts   and   compromises  that  will   do  vastly 

(248) 


Health  Needs  and  Civic  Action  5 

more  harm  to  the  South  than  the  hookworm.  On  the  other  hand, 
by  a  statement  in  his  autobiography  that  there  is  money  and  to 
spare  to  do  the  world's  uplift  work,  the  world's  most  intelligent 
giver  on  a  large  scale  would  have  done  more  good  than  millions 
for  health  or  medical  education.  Therefore,  it  behooves  us  who 
are  enthusiastic  over  the  immeasurable  strides  recently  made  by 
the  "health  movement"  to  consider  the  direction  of  our  thinking 
about  the  work  that  remains  to  be  done. 

Let  us  take  up  some  of  the  alternatives  confronting  rich 
men  and  women,  and  the  still  richer  communities  of  taxpayers 
who  are  confronted  with  the  same  facts  as  are  rich  men  and 
women,  to  illustrate  some  of  the  misconceptions  now  current. 

The  medical  examination  and  inspection  of  school  children 
has  "arrived."  Newspapers  and  magazines  have  given  miles  of 
space  to  describing  the  benefits  to  school  children  from  having 
their  physical  defects  discovered  and  from  being  constantly  pro- 
tected against  the  spread  of  transmissible  diseases.  Taking  one 
hundred  readers  of  The  Annals  at  random,  probably  ninety  of 
them  will  be  under  the  impression  that  certainly  the  greater  num- 
ber of  twenty  million  school  children  are  now  enjoying  the  bene- 
fits of  these  advanced  methods  so  widely  heralded.  The  actual 
condition,  so  far  as  state  laws  are  concerned,  is  that  medical  pro- 
tection to  school  children  is  provided  for  in  but  ten  States.  Even 
in  New  York  State  itself  at  the  present  writing  the  educational 
and  health  officials  are  under  the  impression  that  this  is  not  a 
good  year  to  introduce  a  bill  providing  for  physical  examination 
of  all  children  in  all  schools.  The  only  place  in  the  country  where 
children  in  private  and  parochial  schools,  as  well  as  in  public 
schools,  are  by  law  assured  the  benefit  of  medical  inspection  and 
examination  is  in  the  city  of  Indianapolis.  It  is  true  that  in  al- 
most all  of  the  larger  cities  there  is  now  a  nominal  effort  to 
discover  physical  defects.  It  is  also  true,  unfortunately,  that 
with  few  exceptions,  the  discovery  of  the  physical  defects  goes  no 
farther  than  the  statistical  records  of  the  board  of  education  or 
the  board  of  health. 

In  New  York  City,  which,  because  of  the  large  figures 
necessary  to  describe  its  experience,  is  responsible  for  the  greater 
part  of  the  publicity  on  this  subject,  the  city  superintendent  re- 
ports that  for  the  last  school  year  but  a  little  more  than  one-third 

(249) 


6  The  Annals  of  the  American  Academy 

of  those  in  the  schools  were  examined  at  all,  and  of  264,425  defects 
found,  only  113,278  were  remedied.  To  get  this  total  of  defects 
remedied,  the  health  inspectors  advise  tooth  brushes  as  treatment- 
for  defective  teeth. 

Except  as  money  and  time  are  spent  in  getting  done  what 
now  everybody  knows  ought  to  be  done  for  all  children  in  all 
schools — laws  compelling  examination,  school  nurses  for  exami- 
nation, school  physicians  for  diagnosis,  house-to-house  instruc- 
tion of  parents,  harnessing  hospitals,  philanthropists  and  health 
departments  to  preventive  and  educational  work,  establishment 
of  clinics,  constant  comparison  of  work  attempted  with  work 
done,  hygiene  instruction  and  hygiene  practice  at  school,  which 
will  stop  manufacturing  defects  at  their  source  and  give  the  chil- 
dren right  habits — it  will  be  generations  before  the  majority  of 
our  children  will  have  these  health  rights  which  most  of  us  now 
take  for  granted  they  possess.  The  money  which  will  build  one 
hospital  in  Chicago  would  get  all  schools  in  the  country  under 
this  legitimate  load. 

The  story  of  the  "dental  awakening"  affords  another  illustra- 
tion of  the  need  for  constant  challenge  of  our  expenditures  for 
health.  Men  have  been  pouring  millions  upon  millions  into  hos- 
pitals. It  is  now  admitted  that  many  of  these  millions  have  been 
worse  than  wasted,  because  dental  knowledge  has  not  been  ap- 
plied within  hospital  and  dispensary  walls.  So  much  more  is 
now  being  done  by  dentists  than  was  done  five  years  ago  to 
enlist  the  layman's  co-operation  and  to  emphasize  the  dentist's 
social  mission,  that  even  among  dentists  themselves  the  im- 
pression is  gaining  currency  that  the  world  is  aroused  to  the 
need  for  dental  care.  Many  a  city,  however,  has  had  the  ex- 
perience of  New  York:  (i)  Physical  examination  of  school  chil- 
dren without  proper  examination  of  the  teeth ;  (2)  Piling  up 
records  of  defective  teeth  with  almost  negligible  facilities  for 
securing  treatment;  (3)  Permitting  children's  teeth  to  be  ex- 
tracted when  they  should  be  repaired  and  cleaned ;  (4)  Heralding 
one  or  two  dental  clinics  as  evidence  that  dental  needs  have  been 
recognized;  (5)  Promise  of  wholesale  co-operation  between 
dentists  and  public  schools  with  practically  no  examinations  or 
treatments  of  children.  The  $2,000,000  given  for  dental  clinics 
and  instruction  in  dentistry  in  Boston  could  be  so  used  as  to 

(250) 


Health  Needs  and  Civic  Action  7 

give  a  nation  clean  teeth  and  habits  that  will  preserve  clean 
teeth.     Would  it  be  worth  while? 

The  crusade  against  infant  mortality  has  finally  come  down 
to  the  simple  proposition  of  what  the  mother  knows  and  does 
for  her  baby.  The  only  agency  in  any  community  equipped  to 
do  lOO  per  cent,  of  the  educational  work  that  is  required  to  equip 
mothers  to  save  their  own  babies  is  the  city  or  state  govern- 
ment. Those  most  interested  in  saving  babies  have  the  choice 
of  spending  time  and  money  in  getting  done  lOO  per  cent,  of  the 
educational  work  for  lOO  per  cent,  of  the  mothers  who  need  it, 
or  diverting  public  attention  and  private  funds  to  the  main- 
tenance of  a  few,  nurses  or  a  few  milk  stations,  or,  worse  still,  a 
few  babies'  hospitals.  A\'hen  confronted  with  this  choice  in 
Hoboken,  Mrs.  Robert  L.  Stevens  established  a  memorial  to  her 
husband  which  shall  be  used  "to  increase,  year  after  year,  the 
number  of  mothers  and  fathers  who  will  take  an  interest  in  Ho- 
boken's  city  government,  so  that  schools  shall  be  progressively 
better,  streets  cleaner,  recreation  more  enjoyable,  and  health  rates 
and  civic  ideals  progressively  higher." 

What  promises  to  be  the  most  conclusive  demonstration  in 
infant  care  ever  made  in  this  country  is  that  shortly  to  begin  in 
New  York  City,  where  fifteen  milk  stations  will  be  maintained 
by  the  department  of  health  and  supplemented  by  district  nurses 
in  all  needy  sections.  Attempt  to  picture  lOO  per  cent,  of  the 
problem  has  been  made  by  the  New  York  Milk  Committee,  which 
is  now  asking  for  $300,000  for  enough  milk  stations  so  that  this 
coming  summer  no  baby  and  no  mother  will  be  without  the  direct 
and  constant  educational  influence  of  those  who  know  that  there 
was  absolutely  no  excuse  last  summer  for  losing  3293  babies,  under 
one  year  of  age,  just  "because  the  weather  was  hot." 

The  campaign  for  a  National  Bureau  of  Health  and  for  the 
Children's  Bureau  discloses  elements  which  we  .must  keep  con- 
stantly in  mind  in  any  health  program.  They  emphasize  particu- 
larly the  need  for  funds  ample  to  permit  those  who  conduct 
any  educational  campaign  to  keep  everlastingly  at  it.  The  Com- 
mittee of  One  Hundred  not  only  has  never  had  the  money  which 
its  opportunities  justified  and  required,  but  it  has  never  dared 
to  ask  for  money  enough  to  meet,  for  example,  the  miseducating 
campaign  of  the  quack  medicines  and  quack  medical  men  who 

(251) 


8  The  Annals  of  the  American  Academy 

fear  a  strong  health  policy  at  Washington.  When  we  stop  talk- 
ing of  public  benefactions,  as  if  each  were  an  intelligent  gift  and 
could  possibly  do  no  harm,  it  is  inconceivable  that  again,  as  in  the 
past,  when  this  national  health  policy  needed  public  support,  nearly 
$300,000,000  will  be  given  away  for  public  purposes  by  the  very 
private  citizens  who  refuse  to  help  a  nation-wide  crusade  for 
individual  and  public  health. 

The  National  Children's  Bureau  adds  its  testimony  and,  in 
my  judgment,  its  warning  to  those  who  are  investing  energy  or 
money  in  promoting  health  campaigns.  It  would  have  been  just 
as  easy  to  interest  Theodore  Roosevelt  in  the  possibilities  of  the 
United  States  Bureau  of  Education,  United  States  Bureau  of 
Census,  and  a  United  States  Bureau  of  Health,  as  in  a  special 
not-yet-existing  Children's  Bureau.  The  same  energy  that  tried 
to  arouse  a  country  to  the  need  for  an  additional  agency,  with  an 
income  of  $30,000  or  $40,000  a  year,  could  have  organized  and 
galvanized  these  other  already  existing  agencies,  in  touch  with 
a  half-million  teachers,  fifty  state  and  colonial  superintendents 
of  education,  fifty  state  and  colonial  departments  of  health,  all 
the  city  bureaus  of  vital  statistics,  etc.  We  social  workers  can 
hardly  hope  to  divert  the  millions  upon  millions  of  private 
philanthropy  that  now  pour  into  curative  institutions  over  into 
preventive  work,  if  we  ourselves  fail  to  see  that  our  greatest 
problem,  like  our  greatest  opportunity,  is  in  making  existing 
agencies  efficient,  and  in  getting  done  what  we  all  know  ought 
to  be  done  in  ways  that  we  know  it  should  be  done. 

It  is  one  of  the  anomalies  of  present-day  reform,  and  even 
present-day  health  work,  that  we  undervalue  the  potential  service 
of  the  newspaper,  except  when  we  want  to  make  appeals  for  our 
own  work.  The  Healthgrams  of  Chicago's  health  officer.  Dr. 
William  A.  Evans,  could,  if  generally  known  and  generally  imi- 
tated, do  more  for  nation-wide  promotion  of  health  than  a  thou- 
sand hospitals.  Why  will  we  go  on  believing  it  is  worth  while 
for  private  philanthropists  to  work  in  a  few  spots  a  part  of  the 
time,  while  permitting  newspapers,  street  railways  or  billboards 
to  advertise,  all  of  the  time  to  all  of  the  people,  various  nostrums 
which  aggravate  disease  and  manufacture  misconceptions  on 
which  disease  thrive?  In  two  New  York  Sunday  papers  one 
issue  printed  2y  columns  of  advertising  more  potent  for  evil  than 

(252) 


Health  Needs  and  Civic  Action  9 

2y  cases  of  smallpox  equally  flagrant.  Have  you  ever  compared 
the  amount  spent  in  your  city  by  private  philanthropy  to  fight 
tuberculosis  with  the  amount  spent  by  quacks  to  advertise  quack 
medicines  for  these  same  tuberculous  neighbors? 

Take,  for  instance,  the  campaign  against  infant  mortality.  It 
w^ould  be  an  interesting  study  to  note  on  w^hat  days  of  last  year 
the  newspapers  of  your  city  printed  facts  about  saving  babies. 
Were  these  newspaper  items  and  editorials  addressed  to  the 
mothers  who  have  the  babies,  or  to  the  men  and  women  who 
have  the  money  to  support  private  work?  Did  they  relate  to 
100  per  cent,  of  the  babies,  or  to  one  per  cent,  or  to  10  per  cent,  cared 
for  in  different  private  institutions?  Was  the  maximum  atten- 
tion given  in  the  summertime  when  babies  could  be  saved,  or 
in  wintertime  when  the  annual  reports  of  child-saving  institu- 
tions were  published?  In  New  York  City,  at  the  height  of  the 
infant  mortality  of  last  summer,  toward  the  end  of  June  and  early 
in  July,  day  after  day,  hundreds  of  thousands  of  citizens,  including 
practically  all  mothers  of  young  babies,  read  shouting  headlines 
to  the  effect  that  there  was  no  hope  for  reducing  infant  deaths 
because  the  hot  wave  would  last  another  week.  Private  agencies, 
instead  of  coming  "square  back"  to  the  mothers  through  these  same 
welcome  sources  of  information,  utilized  the  torrid  wave  to  state 
their  own  need  for  funds.  The  health  department  itself  finally 
accepted  the  co-operation  of  the  newspapers,  and  day  after  day  told 
the  New  York  public  that  babies  died  because  the  milk  was  warm 
or  unclean,  and  not  because  the  weather  was  hot  or  baby  was  hot. 

In  my  judgment,  we  cannot  go  much  farther  in  our  health 
crusades  without  more  funds  for  making  such  effective  use  of 
the  newspapers  as  has  characterized  the  crusades  for  legislation 
against  the  white  plague  and  child  labor. 

Propaganda  for  more  laws  or  more  hospitals  makes  news 
more  easily  than  propaganda  for  the  enforcement  of  laws  already 
obtained,  and  the  effective  use  of  hospitals  and  health  agencies 
already  established.  Here  energy  and  money  must  be  spent  in 
getting  facts  about  the  non-enforcement  of  child  labor  and  other 
laws,  and  the  administrative  remedies  for  the  non-enforcement 
of  our  child  labor,  factory,  truancy,  compulsory  education  laws,  etc. 

Just  as  we  are  never  going  to  have  dentists  enough  to  do 
the  repair  work  for  a  nation  with  unclean  teeth,  so  we  are  never 

(253) 


lO  The  Annals  of  the  American  Academy 

going  to  have  private  agencies  enough  to  undo  the  evils  of  in- 
efficient administration  by  public  officials  and  employes  v^ho  are 
working  for  good  or  evil  every  day  in  the  year  w^ith  the  mo- 
mentum of  lOO  per  cent,  of  their  communities.  Clean  streets  are 
more  deadly  enemies  to  tuberculosis  than  are  hospitals  and  dis- 
pensaries. Efficient  state  and  local  departments  of  health  can 
do  more  to  check  transmissible  diseases  than  state  and  local  pri- 
vate organizations.  Getting  loo  per  cent,  of  us  "under  the  load" 
by  placing  our  official  representatives  under  that  load,  with 
methods  that  do  efficient  routine  work,  is  a  duty  imposed  upon 
all  of  us  by  the  growing  interest  in  health  laws.  As  Superintend- 
ent Young  illustrated  by  opening  Chicago's  school  windows,  it 
is  infinitely  more  important  to  give  lOO  per  cent,  of  our  school 
children  proper  ventilation  than  to  start  open-air  classes  for  the 
anaemic  and  tuberculous. 

The  only  time  in  the  year  when  our  communities  attempt  to 
picture  lOO  per  cent,  of  their  health  opportunity  and  health  needs 
is  when  they  are  preparing  their  local  or  state  budgets.  The  only 
document  that  pretends  to  outline  lOO  per  cent,  of  a  community's 
health  needs  is  the  budget  estimate.  The  only  document  that 
pretends  to  describe  loo  per  cent,  of  what  a  community  proposes 
to  do  next  year  for  promotion  of  health  is  the  city  budget.  Yet 
to  a  degree  that  is  astounding,  when  one  considers  public  re- 
sponsiveness to  the  "health  movement,"  budget  estimates,  budget 
hearings,  budget  making  and  budget  possibilities  are  still  un- 
known lands  to  health  crusaders. 

Still  more  of  a  stranger  is  interest  in  the  after-budget  fulfill- 
ment of  before-budget  pledges.  From  one  end  of  the  country  to 
the  other  are  illustrations  in  almost  every  city,  that  getting  money 
voted  for  a  health  purpose  is  by  no  means  the  same  thing  as 
getting  money  used  for  that  health  purpose. 

In  October,  1909,  at  a  taxpayers'  hearing  on  the  budget  for 
the  year  1910,  the  need  for  a  comprehensive  fight  against  tuber- 
culosis was  presented  with  a  skill  and  with  authority  siich  as  were 
probably  never  before  equalled  in  any  public  hearing  in  any 
American  city.  All  the  money  was  voted  that  such  famous  ex- 
perts in  the  fight  against  tuberculosis  as  Robert  W.  DeForest, 
Abraham  Jacobi,  Simon  Flexner,  Woods  Hutchinson,  etc.,  de- 
clared was  needed.     Public  schools,  Bellevue  and  allied  hospitals, 

(254) 


Health  Needs  and  Civic  Action  il 

and  the  health  department,  received  all  the  money  asked  for  the 
tuberculosis  campaign.  Yet  with  two  months'  full  notice  that 
the  money  would  be  available  January  i,  1910,  not  one  of  these 
agencies  was  ready  on  January  ist  to  begin  to  spend  the  money 
as  planned,  and  not  one  of  these  agencies  had  spent  the  money 
as  planned  by  December  31,  1910.  The  health  department  al- 
lowed $4727  in  January,  $2590  in  February  and  $9875  by  July 
31st  to  lapse  for  want  of  organization  and  direction.  Instead  of 
twenty  out-door  school  rooms,  the  board  of  education  equipped 
but  three  and  used  but  two.  (Those  wishing  information  on  bud- 
get making  and  budget  estimates,  budget  hearing  and  after-bud- 
get records  and  accounts  that  will  disclose  the  truth  about  after- 
budget  uses  of  appropriations,  are  referred  to  the  Herman  A. 
Metz  National  Fund  for  Promoting  Efficient  Municipal  Account- 
ing and  Reporting,  261  Broadway,  New  York.) 

Utilization  of  health  knowledge  already  known  requires  at- 
tention now  more  than  the  discovery  of  facts  heretofore  con- 
cealed. With  almost  negligible  exceptions,  we  can  stamp  out 
diseases  common  to  man  without  knowing  one  more  fact  regard- 
ing medicine.  The  great  problem  of  the  next  few  years  is  to 
show  medical  men  themselves  and  philanthropists  who  like  to 
give  money  for  training  medical  men  and  medical  research  that 
the  supreme  need  is  for  administrative  use  of  medical  knowledge 
already  in  hand. 

An  investigation  by  the  Carnegie  Foundation  for  the  Ad- 
vancement of  Teaching  has  given  the  physician's  halo  and  that 
of  the  medical  college  a  pretty  severe  tilt.  Hundreds  of  thou- 
sands of  readers,  who,  until  that  report,  felt  that  medical  schools 
were  distributors  of  health  knowledge,  were  made  to  see  that 
what  the  country  needs  even  more  than  physicians  are  men  and 
women  who  can  teach  to  what  a  very  great  extent  physicians 
are  unnecessary.  For  example,  after  working  for  a  couple  of 
years,  the  Rbckefeller  Fund  seems  to  have  proved  conclusively 
that  the  cure  for  the  hookworm  requires  chiefly  the  application  of  a 
few  elementary  principles  of  cleanliness.  The  great  problem  in  the 
South  seems  to  be,  not  to  find  germs,  analyze  them  and  discover 
means  for  killing  them,  but  to  give  the  Southern  farmer  and  small 
town  modern  standards  of  cleanliness  and  modern  local  and  state 
machinery  for  applying  modern  sanitary  methods  everywhere. 

(255) 


12  The  Annals  of  the  American  Academy 

Likewise  the  union  of  Columbia  University  and  the  Presby- 
terian Hospital  for  the  bedside  training  of  medical  men  raises  a 
question  whether  an  additional  step  must  not  soon  be  taken  to 
supplement  bedside  instruction  with  sewer-side  instruction,  un- 
clean milkshop-side  instruction,  unclean  home-side  instruction, 
uninformed  mothers-side  instruction,  unlighted  tenement-side  in- 
struction, unventilated  factory-side  instruction,  etc. 

It  is  not  true  that  a  cause  is  always  advanced  when  every- 
body comes  to  see  the  necessity  for  promoting-  it,  and  when 
everybody  talks  about  it.  Oftentimes  consciousness  of  social 
need  acts  like  a  drug,  putting  the  public  to  sleep  instead  of  open- 
ing its  eyes,  unless  supplemented  by  administrative  acts  which 
harness  public  conscience  and  public  intelligence  to  efficient  daily 
routine  work. 

Immediately  after  hearing  of  the  Slocum  disaster — the  burn- 
ing of  several  hundred  women  and  children  on  an  excursion  boat 
on  the  Hudson  River — I  telephoned  to  Sea  Breeze  to  ask  about 
our  fire  protection  for  several  hundred  mothers  and  children  on 
fresh-air  outings,  and  for  forty  children  suffering  from  bone 
tuberculosis.  Fire  drills  were  started  at  once,  and  upon  my  first 
visit  I  asked  to  see  one.  The  promptness,  efficiency,  pleasure  and 
order  that  characterized  that  fire  drill  were  a  joy.  There  was 
just  one  defect — nobody  had  been  detailed  to  turn  on  the  water. 
Had  there  actually  been  a  fire,  it  is  not  inconceivable  that  build- 
ings would  have  been  entirely  empty  or  several  lives  lost  before  dis- 
covering it  was  nobody's  business  to  turn  on  the  water. 

This  is  the  condition  of  a  great  number  of  our  health  cru- 
sades at  the  present  time.  The  public  is  convinced,  everybody 
knows  that  water  puts  out  fire,  everybody  knows  that  there  must 
be  organization,  but  in  too  many  instances^  even  when  we  have 
our  fire  drill  organized,  we  have  not  yet  arranged  for  turning  on 
the  water  and  keeping  it  on  until  the  fire  is  out. 

Social  workers  and  the  philanthropists  and  officials  they  try 
to  influence  can  pay  biggest  dividends  these  next  few  years  by 
seeing  and  taking  the  administrative  steps  necessary  to  utilize, 
every  day  in  the  year,  the  knowledge  they  already  possess 
through  the  only  agencies  zvhich  belong  to  all  of  us,  which  make 
mistakes  or  advance  steps  in  the  name  of  all  of  us, — our  city,  county, 
state  and  national  governments. 

(256) 


HOUSING  AND  HEALTH 


By  Lawrence  Veiller, 
Secretary,  National  Housing  Association,   New  York. 


Dirt  and  disease  have  gone  hand  in  hand  too  long.  As 
modern  surgery  owes  its  rapid  strides  to  the  discovery  of  asepsis 
and  the  banishment  of  dirt  from  the  operating  room,  so  modern 
medicine  is  about  to  come  into  its  own  through  the  banishment 
of  dirt  from  our  communal  life.  The  slum,  the  mother  of  disease, 
is  now  doomed.  Its  end  is  in  sight.  From  ocean  to  ocean, 
throughout  the  land,  there  is  a  newly  awakened  consciousness 
of  our  past  folly  and  a  slowly  dawning  perception  of  our  in- 
herent right  to  decent  conditions  of  living. 

We  have  paid  dear  for  our  slums,  and  have  given  hostages  to 
fortune,  leaving  a  heavy  debt  for  posterity  to  liquidate.  No  one 
has  even  attempted  to  estimate  the  cost  to  the  nation  of  our  bad 
housing  conditions,  because  it  is  an  impossible  task.  Who  can 
say  of  the  vast  army  of  the  unemployed,  how  large  a  portion  of 
the  industrially  inefficient  are  so  because  of  lowered  physical 
vitality  caused  by  disadvantageous  living  conditions?  To  what 
extent  is  the  forbidding  atmosphere  of  so  many  homes  an  ele- 
ment in  the  problem  of  inebriety?  Of  the  burdens  which  the 
State  is  called  upon  to  bear  in  the  support  of  almshouses  for  the 
dependent,  hospitals  for  the  sick,  asylums  for  the  insane,  prisons 
and  reformatories  for  the  criminal,  what  portion  can  fairly  be 
attributed  to  adverse  early  environment? 

Despite  our  vaunted  civilization,  our  material  prosperity,  our 
increasing  love  and  appreciation  of  things  artistic,  our  greatly 
improved  architecture,  our  musical  development,  our  mastery  of 
the  mechanical  world,  our  readiness  of  invention,  our  diffusion 
of  education,  our  higher  standards  of  liberty,  in  a  word,  our 
greatly  increased  culture,  we  are  still  in  some  respects  "barbarous 
America."  From  the  past  no  word  comes  to  us  of  the  slums 
of  ancient  Tyre  or  Sardis  or  of  noble  Athens — only  a  faint  breath 
from  decadent  Rome,  to  tell  us  that  the  worst  they  had  did  not 
approach  the  evils  of  present-day  America. 

(257) 


14  The  Annals  of  the  American  Academy 

In  the  great  majority  of  our  cities  we  are  still  in  that  rudi- 
mentary state  of  sanitary  knowledge  where  we  know  no  better 
than  to  surround  ourselves  with  the  vilest  elements  of  human 
waste,  which  we  allow  to  remain  near  the  homes  of  the  poor  for 
long  periods  of  time,  turning  living  places  which  should  be 
gardens  of  delight  and  centers  of  sweet  repose  into  nothing  more 
nor  less  than  disease  factories,  whose  daily  output  is  literally 
disease  and  death.  We  still  suffer  to  remain  in  large  numbers 
even  in  the  crowded  quarters  of  our  cities,  where  the  poor  are 
huddled  close  together,  and  where  disease  spreads  quickly,  thou- 
sands of  vile  privies,  vaults,  sinks,  cesspools,  outdoor  closets, 
"sanitary  conveniences,"  so-called.  No  one  knows  how  many 
thousands  of  these  there  are,  but  the  city  where  they  are  not 
present  in  large  numbers  is  exceptional.  Even  New  York,  with 
its  four  and  three-quarter  millions  of  people,  had  7000  of  them 
up  to  a  few  years  ago.  Baltimore  still  has  70,000  earth  closets, 
and  through  all  her  existence  has  had  no  system  of  public  sewers, 
but  only  now  is  installing  one.  St.  Louis  can  still  show  12,000 
privy  vaults,  Philadelphia  and  Chicago  have  literally  hundreds 
of  thousands  of  outdoor  closets,  and  many  privies  and  cess- 
pools. Indianapolis,  Milwaukee,  Pittsburg,  Cleveland,  Cincin- 
nati, Nashville,  Birmingham — all  have  to  admit  the  presence 
of  these  ancient  evils  by  the  thousands.  The  list  might  be 
added  to  indefinitely.  Hardly  a  city  in  America  is  free  from 
this  blight. 

That  such  conditions  could  prevail  among  the  cultured,  well- 
to-do,  progressive  people  of  America  to  such  degree  is  unthink- 
able. That  people  of  intelligence  and  wealth  would  continue  to 
live  in  such  surroundings  is  not  to  be  believed.  And,  of  course, 
they  do  not.  These  conditions  are  to  be  found  only  among  the 
homes  of  the  poor — in  our  slums,  in  those  foreign  colonies  which 
we  have  allowed  to  spring  up  in  the  various  sections  of  our  cities, 
"empires  within  an  empire,"  segregated  from  American  institu- 
tions, isolated  communities  feeling  but  slightly  the  touch  of 
democracy — "social  Saharas,"  as  they  have  been  aptly  called. 

Just  because  these  evils  have  been  removed  from  our  immediate 
sight  we  have  foolishly  fancied  ourselves  secure,  and  have  believed 
that  they  do  not  touch  us.  But  the  "mighty  miasmatic  breath  blown 
from  the  slums"  penetrates  all  parts  of  the  town.     No  home  is 

(258) 


Housing  and  Health  15 

exempt,  no  person  secure.  Disease,  no  respecter  of  persons,  visits 
all  alike. 

The  so'rdidness  of  it  all,  the  degrading  baseness  of  it,  un- 
fortunately is  withheld  from  the  eyes  of  most  of  us..  What  it 
means  to  the  people  who  have  to  live  in  the  midst  of  it  we  can 
but  faintly  conceive.  Let  us  frankly  admit  that  these  conditions 
result  in  imposing  upon  the  great  mass  of  our  working  people 
habits  of  life  that  are  more  compatible  with  the  life  of  animals 
than  with  that  of  human  beings.  What  it  must  mean  in  its  effect 
on  the  standards  of  decency,  of  modesty,  of  morality  even,  of 
young  girls  growing  into  womanhood,  I  leave  to  the  reader's 
imagination. 

The  effect  upon  health  is  direct  and  intimate.  To  the  de- 
bilitating influence  of  the  noisome  odors  in  the  hot  summer 
weather  may  be  traced  much  of  the  illness  of  the  poor;  to  such 
influences  are  largely  traceable  their  lowered  vitality  and  inability 
to  readily  resist  disease.  The  connection  is  even  more  direct; 
myriads  of  flies  swarm  throughout  the  hot  months,  feed  on  the 
contents  of  the  vaults,  and  then  proceed  to  infect  the  food  supply 
of  the  people  in  the  neighboring  stores,  in  the  kitchens  where 
food  is  preparing — and  with  their  dangerous  burden  crawl  upon 
the  faces  and  bodies  of  the  sleeping  infants  in  the  homes  of  the 
poor.  Nor  do  they  stop  there — even  the  homes  of  the  rich  are 
not  exempt  from  the  dangers  of  the  typhoid  fly. 

That  conditions  such  as  these  should  grow  up  in  a  young 
community  like  America,  without  our  becoming  conscious  of 
them,  is  not  strange,  but  the  time  is  rapidly  passing  when  we 
can  longer  plead  ignorance  and  extreme  youth  as  excuses  for  our 
failure  to  act. 

Few  cities  have  as  yet  dealt  effectively  with  this  situation, 
but,  fortunately,  the  number  which  have  awakened  to  the  sig- 
nificance of  these  conditions  is  constantly  increasing. 

We  are  rapidly  passing  out  of  the  stage  where  the  repre- 
sentative men  of  a  community  with  whispers  discuss  these  evils 
and  in  subdued  tones  deprecate  their  ventilation  on  the  ground 
that  it  is  "bad  for  business"  and  will  "hurt  the  city's  fair  fame." 
Far-seeing  men  realize  that  any  such  ostrich-like  policy  but  post- 
pones the  evil  day,  that  the  continued  tolerance  of  the  conditions 
in  the  long  run  injures  the  city  and  that  a  low  death  rate  and  a 

(259) 


i6  The  Annals  of  the  American  Academy 

well-earned  reputation  as  "a  city  of  homes"  is  one  of  the  best 
assets  a  city  can  have.  Such  men  realize  that  frank,  open- 
minded  discussion  of  health  needs  is  a  prerequisite  to  their 
cure.  Diagnosis  must  precede  treatment.  In  many  cities  groups 
of  business  men,  chambers  of  commerce,  etc.,  are  themselves 
actively  taking  hold  of  these  problems.  They  are  abandoning 
the  policy  of  concealment  and  working  tkat  there  may  be  noth- 
ing to  conceal. 

Strangely  enough,  democracy  itself  seems  to  be  an  obstacle 
to  sanitary  progress.  It  is  a  disconcerting  and  startling  dis- 
covery to  make,  but  the  evidence  is  unmistakable.  In  those  cities 
where  the  "workingman  owns  his  own  home,"  where  there  are 
miles  and  miles  of  small  one-story  and  two-story  houses,  the 
sanitary  authorities  will  tell  you  that  they  have  the  greatest 
difficulty  in  meeting  health  needs,  in  securing  adequate  appro- 
priations, in  enforcing  higher  standards.  A  low  tax  rate  becomes 
in  such  communities  a  fetich  of  sinister  effect.  Where  the  com- 
munity is  made  up  to  a  predominant  degree  of  working  people, 
many  of  whom  "own"  their  own  homes  by  the  payment  of  but 
$2'5  or  $50,  as  is  frequently  the  case,  the  tax  rate  becomes  directly 
felt  to  a  degree  that  cannot  be  appreciated  in  other  communities 
where  the  burden  of  high  taxes  is  more  widely  distributed  and 
is  frequently  disguised  in  the  form  of  rent  and  increased  prices 
of  commodities. 

In  such  cities  every  public  expenditure  is  viewed  with  the 
closest  scrutiny — public  officials,  who  owe  their  office  to  popular 
vote,  are  loath  to  pursue  any  course  of  action  that  will  impose 
upon  the  electorate  at  large  additional  expense.  Bond  issues  for 
needed  public  improvements,  for  installing  a  system  of  public 
sewers,  for  example,  or  for  alley  improvement,  are  often  voted 
only  with  great  difficulty. 

The  small  property  owner,  with  limited  resources,  stagger- 
ing frequently  under  burdens  which  he  should  never  have  placed 
on  his  own  shoulders,  lured  by  "land  hunger,"  and  sometimes  by 
the  hunger  to  be  a  landlord,  is  the  greatest  obstacle  to  progress. 
Burdened  as  he  is,  limited  in  his  intelligence,  his  own  standard 
of  living  low,  his  knowledge  of  sanitary  science  practically  nil, 
it  is  not  strange  that  he  should  not  place  the  welfare  of  the  com- 
munity above  that  of  self-interest,  and  should  not  divorce  in  his 

(260) 


Housing  and  Health  17 

consideration  of  public  questions,  their  effect  on  his  own  pocket 
from  their  vakie  to  his  neighbors  and  to  posterity. 

The  low  standards  of  living  of  such  a  man  are  further  ob- 
stacles to  sanitary  advance.  Living  himself  under  sordid  sur- 
roundings, content  with  the  conditions  that  he  has  known  from 
early  childhood,  he  can  see  no  reason  for  the  new  "fads  and 
fancies"  which  the  health  authorities  would  compel  him  to  pro- 
vide for  his  tenants.  If  vaults  are  good  enough  for  him,  they 
are  quite  good  enough  for  his  tenants,  whom  he  considers  as 
social  and  industrial  inferiors. 

The  false  cry  for  "economy"  which  now  is  so  popular,  and 
which  is  usually  a  cry  for  false  economy,  threatens  to  wreck  our 
institutions.  Its  appeal  to  the  taxpayer  is  immediate  and  satis- 
factory. His  materialistic  sense  is  gratified,  and  he  cares  little 
if  it  means  a  serious  setback  to  the  sanitary  and  social  progress 
of  the  community.  It  will  take  the  country  years  to  recover 
from  its  present  hysterical  outbreak  in  this  direction. 

It  will  be  a  long  time,  I  fear,  before  we  return  to  a  sane 
realization  that  with  our  advancing  standards  of  civilization,  the 
increased  burdens  imposed  by  unrestricted  immigration,  and  our 
constantly  enlarging  conceptions  of  governmental  functions,  ex- 
penses of  government  must  necessarily  increase  from  year  to 
year.  New  sources  of  revenue  must  be  developed,  due  economy 
should  be  practiced,  waste  eliminated  so  far  as  practicable,  but 
retrenchment  in  public  expenditures  should  never  be  made  at 
the  expense  of  the  health  of  the  community. 

It  is  due  largely  to  the  conditions  just  described  that  we 
have  as  yet  in  no  city  dealt  effectively  with  our  alley  problem. 
The  alley  is  both  a  blessing  and  a  curse.  As  a  means  of  letting 
light  and  air  into  the  interior  of  city  blocks  that  would  otherwise 
be  without  it,  it  is  a  distinct  gain.  And  the  few  cities  that  have 
no  alleys  feel  their  misfortune  in  this  regard  most  keenly.  The 
small,  pocketed  back  yards,  shut  away  from  the  free  current  of 
air,  are  unknown  in  the  city  with  alleys.  The  alley  is  generally 
however,  an  evil.  As  a  minor  street,  hidden  away  at  the  rear 
of  everything,  it  becomes  the  dumping  ground  for  all  the  cast-off 
material  of  humanity.  Here  will  be  found  collected,  in  all  stages 
cf  picturesque  disorder  and  sordid  squalor,  all  of  the  unpleasant 
things  of  our  material  existence. 

(261) 


l8  The  Annals  of  the  American  Academy 

The  privies  generally  are  close  to  it.  Piles  of  manure,  those 
pest  factories  which  breed  uncontrolled  the  typhoid  fly  by 
myriads,  frequently  overflow  into  it.  Uncollected  garbage,  in 
the  hot  summer  months,  lies  there  in  decaying  heaps.  Surface 
water,  slops,  wash-tub  emptyings,  leakage  from  privies  and  from 
stables  cover  the  surface  with  slime.  Old  paper,  tin  cans,  rub- 
bish and  refuse  of  every  kind  are  everywhere;  huge  rats,  living 
and  dead,  add  to  the  general  horror. 

In  many  cases,  these  are  the  playgrounds  of  the  children 
of  the  working  people.  In  some  they  are  the  only  approach  to 
their  homes,  the  sole  outlook  upon  life  they  get  from  the  windows 
of  their  dwelling  places.  And  we  wonder  at  the  improvidence 
of  the  poor,  at  their  inebriety,  at  their  shiftlessness !  We  are 
surprised  at  the  burdens  which  the  State  has  to  bear  in  the  sup- 
port of  the  defective  and  delinquent. 

Unpaved,  as  most  alleys  are,  the  cleaning  often  is  a  difficult 
problem.  This  difficulty  is  greatly  enhanced  by  the  fact  that  in 
most  cities  the  city  itself  assumes  no  responsibility  for  their 
cleanliness,  but  looks  to  the  abutting  property  owner  to  perform 
this  function.  The  result  is  what  might  be  expected.  We  years 
ago  passed  beyond  that  stage  of  our  development  where  we 
imposed  on  private  citizens  the  responsibility  for  cleaning  the 
streets  in  front  of  their  houses,  but  we  still,  in  many  cities,  fool- 
ishly expect  them  to  clean  the  streets  in  the  rear.  In  few  cities 
are  the  alleys  policed  or  lighted  at  night.  They  become  often, 
therefore,  the  haunt  of  criminals,  and  naturally  lend  themselves 
to  practices  which  shun  the  light. 

All  of  these  evil  conditions  are  well  recognized  in  most  of 
our  cities,  but  the  same  causes  that  have  tended  to  perpetuate 
the  evils  of  the  privy  vault  have  been  operative  here  as  well. 
The  small  property  owner,  to  whose  wishes  the  elected  public 
official  is  sensitive,  objects  to  assessments  for  paving  the  alleys. 
He  sees  no  "benefit,"  in  the  financial  sense,  to  his  property,  and 
he  is  unwilling,  as  a  rule,  to  be  asked  to  pay  for  an  improvement 
which,  from  his  point  of  view,  does  not  "improve,"  and  which  he 
thinks  too  good  for  the  class  of  people  from  whom  he  draws  his 
revenues. 

The  alley,  if  it  is  to  remain,  must  be  treated  as  a  street.  It 
must  be  paved ;  it  must  be  cleaned  at  regular  intervals,  that  is, 

(262) 


Housing  and  Health  19 

kept  clean,  not  made  clean;  it  must  be  lighted  and  it  must  be 
policed.  Before  any  of  these  things  can  be  done  the  city  must 
officially  assume  responsibility  for  it;  where  it  does  not  already 
own  the  fee,  the  owners  must  dedicate  it  to  the  city. 

The  cry  for  "economy"  and  the  desire  to  keep  down  the  tax 
rate  operate  against  the  carrying  out  of  these  measures.  If  the 
alleys  are  to  be  cleaned  by  the  city  as  often  as  the  streets  are  cleaned, 
the  cost  of  street  cleaning  will  increase  at  least  fifty  per  cent.  So, 
if  they  are  lighted  and  policed,  the  city's  yearly  expense  will  be 
similarly  increased. 

But  it  is  a  false  economy  that  stands  in  the  way  of  carrying 
out  these  greatly  needed  reforms.  It  is  saving  at  the  spigot  and 
wasting  at  the  bung-hole.  We  are  paying  the  cost  now,  in  fact, 
but  in  indirect  and  less  obvious  ways.  It  will  cost  the  city  more 
for  police,  but  less  for  police  courts  and  jails;  more  for  street 
cleaning,  but  less  for  hospitals  and  relief.  It  is  better  economy 
to  keep  people  well  than  to  get  them  well,  to  prevent  crime  than 
to  punish  it.  The  cost  must  be  paid  one  way  or  another.  If 
we  refuse  to  pay  it  in  treasure  now,  we  must  pay  it  in  both 
blood  and  treasure  in  the  end. 

The  filth  and  squalor  which  surround  the  homes  of  the  poor 
in  so  many  of  our  cities  may  be  traced  to  similar  causes.  From 
the  very  nature  of  things,  the  working  people  cannot  be  expected 
to  hire  carts  and  cart  away  the  refuse  which  accumulates.  Nor 
is  there  much  likelihood  of  the  average  landlord  doing  this  under 
the  conditions  of  our  ordinary  urban  existence. 

This  is  a  function  of  the  municipality,  and,  if  the  city  neglects 
it,  the  responsibility  must  be  placed  where  it  belongs,  upon  the 
city  officials  who  are  so  benighted  that  they  do  not  see  the  short- 
sightedness of  their  policy,  and  upon  the  citizens  who  are  so 
penurious  that  they  prefer  to  tolerate  the  evil  conditions  rather 
than  increase  the  cost  of  government.  There  are  few  cities  in 
America  to-day  where  the  garbage  is  collected  with  sufficient 
frequency  or  regularity.  And  the  city  which  collects  rubbish, 
ashes  and  other  waste  is  as  yet  the  exception  rather  than  the  rule. 

Tuberculosis,  that  sinister  terror  of  former  years,  is  thought 
by  many  to  be  about  to  vanish  from  us,  but  sober  vision  indicates 
that  it  will  be  many  years  before  we  see  it  disappear.  Although 
it  would  seem  that  no  one  could  have  escaped  learning  the  im- 

(263) 


20  The  Annals  of  the  American  Academy 

perative  necessity  of  fresh  air  and  sunlight,  yet,  notwithstanding 
that  we  have  been  taught  that  tuberculosis  is  a  "house  disease," 
that  in  dark,  unventilated  rooms  it  thrives  and  flourishes,  and 
that  the  germs  cannot  live  in  strong  sunlight,  yet  in  how  few 
cities  is  the  speculative  builder  restrained  from  adding  new  dark 
rooms  to  swell  the  present  number.  In  growing  Western  cities, 
where  space  is  plentiful  and  land  is  cheap,  new  tenement  houses 
are  built  with  half  the  rooms  dark — it  is  easier  to  do  it  that  way. 
And,  as  a  nation,  we  normally  choose  the  easiest  way.  In  no 
city.  East  or  West,  have  we  so  far  progressed  as  to  prohibit  in 
our  private  dwellings  and  our  public  buildings  rooms  without 
direct  outside  light  and  air.  Everywhere,  irrespective  of  land 
values,  one  encounters  an  intense,  individualistic  desire  to  cover 
over  an  undue  amount  of  the  lot,  and  occupy,  if  possible,  every 
foot  of  land. 

In  our  houses  on  wheels,  the  railroad  cars  and  trolleys, 
where  disease  spreads  most  easily  and  rapidly,  we  have  just  be- 
gun to  enforce  standards  of  ventilation ;  one  might  almost  say 
we  have  hardly  commenced  it.  In  our  public  buildings  we  are 
still  in  the  dark  ages;  our  court  houses,  our  municipal  and  state 
buildings,  our  schools  and  churches,  our  workshops,  our  theaters 
and  the  moving  picture  shows,  where  so  many  hundreds  of  thou- 
sands of  people  congregate  nightly,  proper  ventilation  is  the  ex- 
ception rather  than  the  rule. 

We  have  a  long  and  difficult  campaign  of  education  ahead 
of  us  before  we  can  approach  reasonable  health  standards  in 
this  regard.  Most  people  do  not  want  fresh  air  in  their  homes  or 
elsewhere.  It  is  not  only  "night  air"  that  is  dreaded,  but  all  fresh 
air.  Let  a  man  open  a  window  in  a  railroad  train,  or  trolley  car, 
or  even  at  a  convention  of  physicians  or  sanitarians,  and  see  what 
happens.  How  quickly  some  one  closes  it  who  cannot  stand  "the 
draft."  All  the  ignorance  in  this  regard  cannot  be  charged  to  the 
"great  unwashed." 

Viewing  these  conditions,  it  seems  premature,  at  least,  to 
talk  of  establishing  "garden  cities"  and  "zone  systems."  These 
highly  desirable  ideals,  so  successfully  carried  out  in  the  Old 
World,  must  wait  until  we  can  bring  ourselves  to  attend  to  the 
elementary  principles  of  sanitation  and  the  rudimentary  prin- 
ciples of  community  living.     It  is  as  if  the  doctor  attending  a 

(264) 


Housing  and  Health  2i 

patient  desperately  ill  with  typhoid  or  pneumonia  were  to  con- 
cern himself  before  the  crisis  of  the  disease  had  passed  with  the 
patient's  diet  during  the  convalescent  stage.  We  have  not 
yet  reached  the  convalescent  stage,  but  are  still  battling  for  the 
patient's  life. 

Underlying  all  of  the  evils  we  have  thus  far  discussed  is 
our  failure,  as  a  nation,  to  develop  sanitary  inspection  as  a  vital 
adjunct  of  municipal  administration.  We  lead  the  world  in  the 
development  of  the  science  of  sanitary  plumbing,  in  our  ready 
adaptation  of  new  mechanisms  and  devices,  the  products  of  our 
inventive  genius,  but  sanitary  inspection  here  is  still  in  its  in- 
fancy. 

In  most  cities  it  is  still  unexplored  territory.  With  two 
exceptions,  New  York  and  Chicago,  no  city  in  America  has  as 
yet  developed  a  system  of  inspection  that  is  worthy  of  the  name 
of  system.  And  even  in  these  two  cities  only  a  beginning  has 
been  made. 

In  the  majority  of  cases  we  are  still  employing  methods  that 
belong  to  the  pre-glacial  period  of  sanitary  science.  In  prac- 
tically all  our  health  departments  we  sit  down  now,  as  we  did 
years  ago,  and  placidly  await  "citizens'  complaints"  of  unsanitary 
conditions,  assuming  that,  when  we  have  attended  to  these  we 
have  done  all  that  need  be  done.  Perhaps,  when  we  were  a 
homogeneous  nation  of  American  citizens,  it  was  safe  to  trust 
to  this  method,  but  that  period  has  long  passed.  With  our  for- 
eign "colonies"  in  every  city,  with  the  mass  of  our  working 
population  made  up,  more  and  more,  of  the  peasantry  of  Europe, 
ignorant  of  our  language  and  customs,  unused  to  our  standards 
of  living,  and  unable  to  make  articulate  their  dissatisfaction  with 
the  conditions  under  which  they  are  compelled  to  live,  we  can 
no  longer  look  to  any  such  methods  of  discovering  and  remedy- 
ing sanitary  evils. 

Many  of  the  poor  in  our  large  cities  do  not  know  that  there 
is  such  a  thing  as  a  board  of  health ;  of  those  who  do  know  of 
its  existence,  few  know  where  to  find  its  offices,  or,  if  aware, 
cannot  afford  the  time  to  travel  to  them  to  call  attention  to  evil 
conditions,  and  the  great  mass  is  too  illiterate  to  send  written 
complaints.  Back  of  it  all,  too,  is  the  certain  knowledge,  gained  • 
from  bitter  past  experience,  that  if  the  source  of  the  complaint 

(265) 


22  The  Annals  of  the  American  Academy 

is  discovered,  eviction  by  the  landlord  is  sure  to  follow.  So,  the 
worst  conditions  remain  undiscovered,  for  weeks,  often  for 
months,  sometimes  for  years,  and  the  poor  finally  become  hard- 
ened to  them,  believing  them  unescapable  and  inherent  in  poverty 
itself. 

This  system,  too,  has  interesting  "by-products"  which  the 
student  of  social  and  municipal  affairs  should  not  overlook.  It 
makes  for  unfair  discrimination.  It  seems  to  indicate  to  the  land- 
lord whose  property  is  frequently  complained  against  that  he  is 
singled  out,  "persecuted,"  as  he  puts  it,  when  he  sees  worse  con- 
ditions in  neighboring  property  tolerated  and  left  alone.  Nothing 
can  convince  him  that  it  is  not  due  to  political  "pull"  on  the 
part  of  his  neighbor  that  he  is  able  to  escape  attention.  He  is 
prone  to  charge  graft,  politics  and  crookedness  to  the  admin- 
istration, and  thus  there  is  bred  in  the  public  mind  that  distrust 
of  popular  government  which  is  rapidly  making  the  holding  of 
public  office  unattractive. 

In  place  of  this  casual,  haphazard  method  there  must  be 
substituted  the  only  system  of  sanitary  inspection  that  is  worthy 
of  the  name.  Instead  of  sitting  calmly  waiting  for  complaints, 
health  inspectors  must  systematically  go  about  "looking  for 
trouble" — they  will  find  plenty.  Instead  of  sending  a  man  to 
look  at  one  thing  in  one  house,  beranse  jt^is  complained  about, 
there  should  be  a  well-trained  corps  of  men  going  over  every 
part  of  the  homes  of  the  poor,  systematically  and  thoroughly, 
scrutinizing  carefully  every  part  of  the  building  where  trouble 
might  naturally  be  expected — all  the  probable  danger  points. 
Such  inspection  would  include  the  cellar,  the  water  closets  and 
privies,  the  public  halls  and  stairs,  the  roof,  the  out-premises, 
the  individual  apartments  and  the  plumbing,  with  especial  em- 
phasis laid  on  the  public  parts  of  the  building.  ,  It  should  be 
done  on  the  health  board's  initiative,  and  should  be  periodic, 
that  is,  at  sufficiently  frequent  intervals  to  ensure  the  main- 
tenance of  the  homes  of  the  poor  in  proper  sanitary  condition. 
Once  a  month  is  the  ideal.  Once  a  year  is  the  minimum.  Three 
times  a  year  should  be  practicable  in  most  cities. 

Coupled  with  this  inspection  to  discover  sanitary  evils  so 
that  they  may  be  abated,  there  should  go  a  system  of  "instructive 
sanitary  inspection"  by  trained  women  inspectors.     It  sounds 

(266) 


Housing  and  Health  23 

paternalistic,  but  we  might  as  well  face  the  fact  that  many  of 
the  poor  must  be  taught  how  to  live.  This  is  especially  true  of 
the  inhabitants  of  our  large  foreign  "colonies."  To  many  of  them 
American  standards  of  living  are  totally  new.  They  have  no 
conception  of  the  functions  of  modern  plumbing,  for  instance, 
and  often  fail  to  realize  that  methods  of  waste  disposal  which 
were  satisfactory  to  them  in  sparsely  settled  country  districts 
of  rural  Europe,  and  which  there  brought  no  evils  in  their  train, 
may  not  safely  be  followed  in  the  more  closely  built-up  sections 
of  our  urban  communities. 

Instruction  of  this  kind  must  necessarily  be  undertaken  with 
the  mothers  and  children.  In  the  homes  it  must  be  given  by 
women,  and  women  who  have  the  power  and  authority  to  follow 
up  their  advice  with  orders,  when  necessary.  Much  can  be  done 
in  the  schools.  Whatever  is  done  should  be  done  in  a  practical 
way,  with  apt  illustration,  and  through  direct  personal  influence, 
rather  than  by  distribution  of  "literature." 

It  is  easy  to  say,  "These  things  should  be  done,"  and  they 
commend  themselves  at  once  to  most  minds.  In  only  two  cities 
in  the  United  States,  however,  New  York  and  Chicago,  is  a  sys- 
tem of  periodic  sanitary  inspection  carried  on.  And  in  only  one 
city  is  any  work  being  done  along  the  lines  of  "instructive  san- 
itary inspection." 

Why,  one  asks,  should  American  cities  be  so  far  behind  the 
enlightened  standards  of  sanitary  science?  Partly  because  we 
have  drifted  along,  choosing  the  line  of  least  resistance,  and 
partly  because  we  have  fallen  into  a  rut  in  our  health  work  and 
have  only  just  begun  to  stand  off  and  look  at  it  and  weigh  its 
value. 

The  failure  to  progress  faster  and  to  reach  higher  standards 
is,  however,  due  to  far  more  fundamental  causes.  We  have 
hitherto  not  been  civilized  enough  or  intelligent  enough  to  be 
willing  to  spend  money  for  the  preservation  of  health.  In  hun- 
dreds of  cities,  still,  the  health  commissioner  receives  no  com- 
pensation, or  so  slight  a  one  that  he  can  afford  to  give  but  a 
small  portion  of  his  time  to  the  work. 

In  every  city  in  the  country  the  health  department  is  terribly 
undermanned.  It  cannot  begin  to  attempt  to  do  what  it  knows 
to  be  imperatively  necessary  for  the  city's  welfare.     I  can  con- 

(267) 


24  The  Annals  of  the  American  Academy 

ceive  of  no  more  trying-  situation  than  that  which  most  of  our 
earnest  and  conscientious  health  commissioners  encounter  year 
after  year,  having  to  sit  helplessly  by  and  see  their  recommenda- 
tions ignored,  and  the  annual  toll  for  unnecessary  disease  and 
death  increase  year  after  year.  The  blame  for  the  evil  condi- 
tions cannot  be  laid  at  the  doors  of  our  health  officials.  With 
but  iew  exceptions,  they  have  done  their  part,  and  if,  after  years 
of  effort  of  this  kind,  they  finally  lapse  into  a  state  of  hopeless 
indifference,  they  are  not  to  be  blamed.  Who  would  not  give 
up  hope  under  such  circumstances?  The  blame  must  be  placed 
on  us  all — on  the  whole  community,  on  our  best  citizens,  and 
our  worst.  It  is  our  fault  and  no  one's  else  that  these  conditions 
continue. 

We  have  been  so  stupid  or  so  careless  that  we  have  paid 
little  or  no  attention  to  our  slums.  We  have  been  willing  to 
spend  money  lavishly  to  protect  property,  but  not  to  protect 
human  life  and  health.  Large  sums  we  grant  annually -in  all 
our  cities  for  the  support  of  the  police  and  fire  departments, 
but  we  grudgingly  apportion  mere  pittances  to  our  health  de- 
partments. 

In  New  York  i^  per  cent,  of  the  city's  annual  expenditures 
is  for  health  work,  as  compared  with  5  per  cent,  for  fire  protec- 
tion, 9  per  cent,  for  the  police,  and  17  per  cent,  for  education. 
And  New  York  leads  the  country  in  its  health  expenditures  and 
has  more  generous  treatment  in  this  regard  than  any  other  city 
in  America.  And  yet,  even  in  New  York  last  year,  where  its 
efficient  health  commissioner  certified  that  the  welfare  of  the  city 
required  the  expenditure  of  $4,076,578  for  health  work  during 
the  coming  year,  the  financial  authorities  granted  him  but 
$2,823,499. 

What  are  we  to  think  of  a  city  like  Chicago,  with  all  its 
wealth  and  culture,  where  the  city  authorities  pay  no  heed  to 
the  statement  of  the  expert  head  of  its  health  department,  that 
$1,500,000  is  requisite  to  meet  the  health  needs  of  the  city,  and 
allow  him  little  more  than  one-third  of  that  amount?  And  this 
in  the  face  of  a  campaign  of  education,  in  which  the  health  au- 
thorities showed  just  what  the  citizens  of  Chicago  could  buy 
with  their  money  in  the  way  of  health. 

In  the  face  of  such  statements  as  the  following,  coming  from 

(268) 


Housing  and  Health  25 

the  highest  official  authority,  it  is  difficult  to  understand  how 
such  a  decision  could  have  been  reached: 

Chicago  now  has  a  21-cent  per  capita  health  department.  A  21-cent 
health  department  for  Chicago  can  hold  the  gross  death  rate  under  16 
per  1000  for  a  few  years.  It  can  hold  the  number  of  deaths  from  diphtheria 
at  about  800;  from  scarlet  fever  at  about  600;  typhoid  at  about  300,  and 
baby  deaths  from  summer  complaint  at  about  3000.  It  can  keep  smallpox 
epidemics  at  about  twelve  years  apart,  and  paralyzing  epidemics  of  diphtheria 
or  scarlet  fever  about  four  or  six  years  apart. 

A  health  department  spending  50  cents  per  capita  should  put  diphtheria 
down  to,  say,  100  deaths  per  year ;  scarlet  fever  to  about  500 ;  typhoid  to 
120,  and  cut  off  5  per  cent,  from  the  consumption  mortality.  It  should  be 
able  to  add  10  years  to  the  smallpox  intervals  and  3  or  4  years  to  the 
diphtheria  and  scarlet  fever  intervals. 

The  final  conclusion  is  that  we  can  have  freedom  from  preventable  dis- 
eases in  proportion  as  we  are  willing  to  pay  for  it.  We  cannot  have  something 
for  nothing.  A  21-cent  health  department  means  about  15,000  deaths  from 
preventable  disease  a  year.  If  we  pay  more,  we  will  have  fewer.  If  we  pay 
less,  we  shall  have  more. 

Which  shall  it  be:  Dollars  or  deaths? 

In  the  last  analysis,  it  all  resolves  itself  back  to  the  degree 
of  intelligence  and  enlightened  public  sentiment  which  are  to 
be  found  in  the  community. 

Still,  the  outlook  for  the  future  is  hopeful.  We  are  passing 
out  of  the  dark  ages  of  sanitary  science.  Housing  and  health 
are  receiving  each  year  increased  attention,  increased  thought. 
We  are  rapidly  ceasing  to  be  "barbarous  America." 


(269) 


SCIENTIFIC  RESEARCH  BY  THE  PUBLIC  HEALTH 

SERVICE 


By  J.  W.  Kerr,  M.D., 

Bureau  of  Public  Health  and  Marine  Hospital  Service,  Treasury  Department 

Washington,  D.  C. 


The  increasing  complexity  of  modern  society  gives  rise  con- 
tinually to  new  sanitary  problems  which  must  be  solved  and  the 
results  applied  if  we  would  escape  race  deterioration  and  loss  of 
industrial  prosperity.  Under  present  conditions  the  individual  is 
himself  unable  to  exercise  all  these  measures  of  protection.  Public 
health  administration  is  therefore  necessary,  and  one  of  its  import- 
ant functions  is  scientific  research. 

Governmental  activities  in  the  field  of  preventive  medicine  have 
accordingly  included  systematic  investigations,  practically  all  mod- 
ern governments  having  made  more  or  less  provision  for  them,  de- 
pending on  the  special  problems  presented  for  solution.  A  com- 
parative statement  of  such  provisions  in  the  several  countries  and 
their  influence  on  the  public  health  would  be  of  interest,  and  in  the 
United  States  would  necessarily  include  those  of  the  federal,  state, 
and  municipal  governments.  It  is  practicable  here  to  describe  only 
the  activities  of  the  Federal  Public  Health  Service,  which  service, 
however,  is  but  a  part  of  the  public  health  organization  of  the 
country;  the  state  and  municipal  health  agencies  being  also  in- 
cluded, and  all  being  related  by  law  and  by  reason  of  their  common 
object. 

While  the  triple  relation  mentioned  has  probably  resulted  in 
the  past  in  a  distribution  of  scientific  effort  and  consequently  limited 
centralization,  on  the  whole  it  has  been  responsible  for  an  immense 
amount  of  work  of  the  greatest  importance,  and  it  is  a  striking 
fact  that  in  addition  to  the  several  public  health  laboratories  of  the 
federal  government  there  is  authority  in  law  for  laboratories  in  no 
less  than  twenty  states. 

The  present  official  interpretation  put  upon  the  constitution 
prevents  the  federal  government  from  exercising  police  powers  with 

(270) 


Scientific  Research  by  the  Public  Health  Service  27 

respect  to  sanitation  within  the  states  themselves.  This  restriction, 
consequently,  modifies  to  some  extent  the  character  of  the  investi- 
gations by  the  Federal  Public  Health  Service ;  but  does  not  limit 
their  scope,  which  embraces  laboratory  studies  of  all  matters  per- 
taining to  the  public  health  and  the  dissemination  of  the  informa- 
tion thus  acquired. 

Organized  originally  to  provide  care  and  treatment  for  sick 
and  injured  sailors  of  the  merchant  marine,  the  Public  Health  Ser- 
vice has  had  a  steady  growth,  having  from  time  to  time  been 
charged  with  additional  duties  and  granted  greater  powers.  These 
additional  duties  included  the  .prevention  of  the  introduction  of 
contagious  and  infectious  diseases  and  their  spread  from  one  state 
to  another,  the  medical  inspection  of  arriving  aliens,  the  supervision 
over  the  propagation  and  sale  of  viruses,  serums  and  toxins,  and  in 
connection  with  all  of  them  there  was  necessity  of  scientific  in- 
vestigations. 

The  Hygienic  Laboratory 

The  activities  in  the  field  of  scientific  research  may  accordingly 
be  said  to  have  originated  when  these  additional  duties  were  as- 
sumed, and  to  have  taken  definite  shape  with  the  establishment  of 
the  hygienic  laboratory  at  the  Marine  Hospital,  New  York,  in  1887, 
Their  inception  therefore  was  practically  coincident  with  the  be- 
ginning of  the  growth  of  the  science  of  bacteriology,  which  may  be 
said  to  mark  the  start  of  the  present  public  health  movement  that 
has  now  assumed  world-wide  proportions.  It  soon  became  evident 
that  the  foundations  of  public  health  research  should  be  laid  at  the 
seat  of  government,  and  the  laboratory  was  accordingly  moved  to 
Washington  in  189 1.  — • 

Since  the  quarantine  act  of  February  15,  1893,  imposed  on  the 
service  the  devising  of  regulations  and  their  enforcement,  for  the 
prevention  of  the  introduction  of  infectious  and  contagious  dis- 
eases, and  since  the  etiology,  methods  of  transmission  and  pre- 
vention of  some  of  those  diseases  was  then  but  indefinitely  under- 
stood, there  was  necessity  of  special  studies  of  those  subjects.  In 
the  early  nineties,  therefore,  increasing  attention  was  paid  to  the 
developing  science  of  bacteriology  and  its  bearing  on  preventive 
medicine.    Officers  attached  to  the  Hygienic  Laboratory  were  sent 

(271) 


28  The  Annals  of  the  American  Academy 

abroad  to  acquaint  them  with  the  methods  employed  in  foreign 
laboratories  and  the  progress  made.  By  this  means,  for  instance, 
knowledge  was  had  of  the  methods  of  propagating  an  immunizing 
serum  for  use  in  the  treatment  and  prevention  of  diphtheria,  and  as 
a  result  diphtheria  antitoxin  was  first  made  in  the  United  States  in 
the  Hygienic  Laboratory  in  November,  1894. 

Studies  were  likewise  made  of  disinfectants  to  determine  their 
germicidal  value  and  best  methods  of  application,  and  for  the  gen- 
eration of  sulphur  dioxide,  furnaces  were  devised  which,  with  but 
slight  improvement,  are  now  in  use  at  the  national  quarantine  sta- 
tions. An  autoclave  for  the  evolution  of  formaldehyde  gas  was 
also  invented  and  the  best  method  of  using  it  determined.  These 
and  many  other  practical  discoveries  indicate  that  substantial  prog- 
ress was  made,  and  that  the  Hygienic  Laboratory  was  developing 
into  an  important  center  for  research  in  public  health  problems. 

In  the  meantime  important  scientific  studies  were  also  being 
made  by  officers  in  the  field,  particularly  in  connection  with  epidemic 
work ;  those  of  Carter  on  the  period  of  incubation  of  yellow  fever 
having  had  a  most  important  bearing  on  the  subsequent  investiga- 
tions of  that  disease.  In  fact,  his  recorded  observations  on  this 
point  were  hardly  less  important  than  Finlay's  hypothesis  in  laying 
the  foundation  for  success  in  the  final  demonstration  of  the  trans- 
mission of  yellow  fever. 

The  outbreak  of  plague  in  Hongkong  in  1894,  which  proved 
to  be  the  beginning  of  the  present  pandemic  of  the  disease,  also 
stimulated  research  as  to  its  nature  and  methods  of  prevention. 
There  was  therefore  prepared  in  the  Hygienic  Laboratory,  at  the 
proper  time,  large  quantities  of  the  prophylactic  vaccine  for  dis- 
tribution in  case  the  disease  should  be  introduced,  and  bulletins 
containing  the  latest  knowledge  regarding  plague  were  distributed 
for  the  information  of  public  health  officials  and  the  public  gen- 
erally. By  these  means  officers  of  the  service  became  familiar  with 
plague  and  were  thus  qualified  to  undertake  quarantine  duty  at  both 
domestic  and  foreign  ports,  and  when  the  disease  actually  gained  a 
foothold  on  the  Pacific  Coast  they  were  prepared  to  recognize  and 
combat  it. 

Prior  to  1902  the  Hygienic  Laboratory  had  been  devoted 
almost  entirely  to  research  in  pathology  and  bacteriology,  but  a  lab- 

(272) 


Scientific  Research  by  the  Public  Health  Serz'ice  29 

oratory  building  had  been  authorized  by  Congress  in  March  of  the 
preceding  year,  and  it  became  evident  that  in  order  to  discharge  the 
functions  for  which  it  was  created,  and  which  were  demanded  in 
the  pubHc  interest,  there  should  be  some  enlargement  of  scope  and 
reorganization  on  broader  lines. 

In  accordance  with  an  act  of  Congress  of  July  i,  1902,  re- 
organizing the  service,  therefore,  there  were  created  three  new 
divisions,  which  made  in  all  four  divisions  of  the  Hygienic  Labora- 
tory, designated  respectively  as:  pathology  and  bacteriology,  medi- 
cal zoology,  pharmacology  and  chemistry.  This  act  also  provided 
for  an  advisory  board  of  nine  members,  four  of  whom  are  officers 
of  the  government,  and  the  remaining  five  eminent  in  their  respec- 
tive fields  and  connected  with  private  educational  institutions.  By 
this  means  the  laboratory  is  brought  in  touch  with  like  institutions 
and  the  surgeon-general  can  secure  advice  with  respect  to  the  in- 
vestigations to  be  made  and  the  methods  of  making  them. 

It  had  long  been  the  practice  to  make  record  in  the  annual 
reports  of  the  work  accomplished,  or  in  the  public  health  reports 
which  have  been  published  weekly  since  1885,  and  in  some  instances 
special  brochures  were  issued  independent  of  these  publications 
But  with  the  reorganization  of  the  service  in  1902  it  was  apparent 
that  the  results  of  investigations,  in  order  to  be  of  the  most  benefit, 
should  be  published  as  Hygienic  Laboratory  Bulletins,  Since  that 
time  seventy-three  such  bulletins  have  been  issued,  their  titles  being 
as  follows: 

Preliminary  Note  on  the  Viability  of  the  Bacillus  pestis. 

Formalin  Disinfection  of  Baggage  without  Apparatus. 

Sulphur  Dioxid  as  a  Germicidal  Agent. 

Viability  of  the  Bacillus  pestis. 

An  Investigation  of  Pathogenic  Microbe  (B.  typhi  murium  Danyz)   Ap- 
plied to  the  Destruction  of  Rats. 

Disinfection  against  Mosquitoes  with  Formaldehyde  and  Sulphur  Dioxid. 

Laboratory  Technique :   Ring  Test   for   Indol ;    Collodium   Sacs ;    Micro- 
photography  with  Simple  Apparatus. 

Laboratory  Course  in  Pathology  and  Bacteriology. 

Presence  of  Tetanus  in  Commercial  Gelatin. 

Report  upon  the  Prevalence  and  Geographic  Distribution  of  Hookworm 
Disease  (Unciniariasis  or  Anchylostomiasis)  in  the  United  States. 

An  Experimental  Investigation  of  Trypanosoma  lewisi. 

The    Bacteriological    Impurities    of    Vaccine    Virus;    an    Experimental 
Study. 

(273) 


30  The  Annals  of  the  American  Academy 

A  Statistical  Study  of  the  Intestinal  Parasites  of  500  White  Male 
Patients  at  the  United  States  Government  Hospital  for  the  Insane.  A 
Parasitic  Roundworm  (Agamomermis  culicis  n.g.,  n.sp.)  in  American  Mos- 
quitoes {Culex  sollicitans).  The  Type  Species  of  the  Cestode  Genus  Hyme- 
nolepis. 

Spotted  Fever  (Tick  Fever)   of  the  Rocky  Mountains;  a  New  Disease. 

Inefficiency  of  Ferrous  Sulphate  as  an  Antiseptic  and  Germicide. 

The  Antiseptic  and  Germicidal  Properties  of  Glycerin. 

Illustrated  Key  to  the  Trematode  Parasites  of  Man. 

An  Account  of  the  Tapeworms  of  the  Genus  Hymenolepis  Parasitic  m 
Man,  Including  Reports  of  Several  New  Cases  of  the  Dwarf  Tapeworm 
(//.  nana)   in  the  United  States. 

A  Method  of  Inoculating  Animals  with  Precise  Amounts. 

A  Zoological  Investigation  into  the  Cause,  Transmission  and  Source 
of  Rocky  Mountain  "Spotted  Fever." 

The  Immunity  Unit  for  Standardizing  Diphtheria  Antitoxin  (Based  on 
Ehrlich's  Normal  Serum).  Official  Standard  Prepared  under  the  Act  Ap- 
proved July  I,  1902. 

Chloride  of  Zinc  as  a  Deodorant,  Antiseptic,  and  Germicide. 

Changes  in  the  Pharmacopoeia  of  the  United  States  of  America. 

The  International  Code  of  Zoological  Nomenclature  as  Applied  to  Medi- 
cine. 

Illustrated  Key  to  the  Cestode  Parasites  of  Man. 

On  the  Stability  of  the  Oxidases  and  their  Conduct  toward  Various 
Reagents.  The  Conduct  of  Phenolphthalein  in  the  Animal  Organism.  A 
Test  for  Saccharin,  and  a  Simple  Method  of  Distinguishing  between  Cumarin 
and  Vanillin.  The  Toxicity  of  Ozone  and  Other  Oxidizing  Agents  to 
Lipase.  The  Influence  of  Chemical  Constitution  on  the  Lipolytic  Hydrolysis 
of  Ethereal  Salts. 

The  Limitations  of  Formaldehyde  Gas  as  a  Disinfectant  with  Special 
Reference  to  Car  Sanitation. 

A  Statistical  Study  of  the  Prevalence  of  Intestinal  Worms  in  Man. 

A  Study  of  the  Cause  of  Sudden  Death  Following  the  Injection  of 
Horse  Serum. 

I.  Maternal  Transmission  of  Immunity  to  Diphtheria  Toxine.  II.  Ma- 
ternal Transmission  of  Immunity  to  Diphtheria  Toxine  and  Hypersuscepti- 
bility  to  Horse  Serum  in  the  Same  Animal. 

Variations  in  the  Peroxidase  Activity  of  the  Blood  in  Health  and 
Disease. 

A  Stomach  Lesion  in  Guinea  Pigs  Caused  by  Diphtheria  Toxine  and  Its 
Bearing  upon  Experimental  Gastric  Ulcer. 

Studies  in  Experimental  Alcoholism. 

I.  AgamoHlaria  georgiana  n.sp.,  an  Apparently  New  Roundworm  from 
the  Ankle  of  a  Negress.  IT.  The  Zoological  Characters  of  the  Roundworm 
Genus  Filaria  Mueller,  1787.  III.  Three  New  American  Cases  of  Infection 
of  Man  with  Horsehair  Worms  (Species  Pagordius  varius),  with  Summary 
of  All  Cases  Reported  to  Date. 

(274) 


Scientific  Research  by  the  Public  Health  Service  31 

Report  of  the  Origin  and  Prevalence  of  Typhoid  Fever  in  the  District 
of  Columbia. 

Further  Studies  upon  Hypersusceptibility  and  Immunity. 

Index-Catalogue  of  Medical  and  Veterinary  Zoology.  Subjects:  Trema- 
toda  and  Trematode  Diseases. 

The  Influence  of  Antitoxin  upon  Post-diphtheritic  Paralysis. 

The  Antiseptic  and  Germicidal  Properties  of  Solutions  of  Formaldehyde 
and  their  Action  upon  Toxines. 

I.  The  Occurrence  of  a  Proliferating  Cestode  Larva  (Sparganum  pro- 
liferu»\)  in  Man  in  Florida.  2.  A  Re-examination  of  the  Type  Specimen 
of  Filaria  restiformis.  3.  Observations  of  Two  New  Parasitic  Trematode 
Worms:  Homalogaster  philippincnsis  n.sp.,  Agamodistanum  nanus.  A  Re- 
examination of  the  Original  Specimen  of  Taenia  saginata  abietina  (Wein- 
land,  1858). 

Milk  and  its  Relation  to  the  Public  Health. 

The  Thermal  Death  Points  of  Pathogenic  Micro-organisms  in  Milk. 

The  Standardization  of  Tetanus  Antitoxin  (an  American  Unit  Estab- 
lished under  Authority  of  the  Act  of  July  i,  1902). 

Report  No.  2  on  the  Origin  and  Prevalence  of  Typhoid  Fever  in  the 
District  of  Columbia. 

Further  Studies  upon  Anaphylaxis. 

Hepatazoon  pemiciosum  (n.g.,  n.sp.)  ;  a  Haemogregarine  Pathogenic  for 
White  Rats;  with  a  Description  of  the  Sexual  Cycle  in  the  Intermediate 
Host,  a  Mite. 

Studies  on  Thyroid:  I.  The  Relation  of  Iodine  to  the  Physiological 
Activity  of  Thyroid  Preparations. 

The  Physiological  Standardization  of  Digitalis. 

Digest  of  Comments  on  the  United  States  Pharmacopoeia.  Eighth  De- 
cennial Revision  for  the  Period  Ending  December  31,  1905. 

Further  Studies  upon  the  Phenomenon  of  Anaphylaxis, 

Chemical  Tests  for  Blood. 

Report  No.  3  on  the  Origfin  and  Prevaknce  of  Typhoid  Fever  in  the 
District  of  Columbia. 

The  Influence  of  Certain  Drugs  upon  the  Toxicity  of  Acetanilide  and 
Antipyrine. 

The  Fixing  Power  of  Alkaloids  on  Volatile  Acids  and  its  Application  to 
the  Estimation  of  Alkaloids  with  the  Aid  of  Phenolphthalein  or  by  the 
Vollhard  Method. 

Quantitative  Pharmacological  Studies:  Adrenalin  and  Adrenalin-like 
Bodies. 

Milk  and  Its  Relation  to  the  Public  Health. 

I.  The  Presence  of  Tubercle  Bacilli  in  the  Circulating  Blood  in  Clinical 
and  Experimental  Tuberculosis.     II.  The  Viability  of  the  Tubercle  Bacillus. 

Digest  of  Comments  on  the  Pharmacopoeia  of  the  United  States  of 
America  (Eighth  Decennial  Revision)  and  the  National  Formulary  for  the 
Period  Ending  December  31,  1906. 

(275) 


32  The  Annals  of  the  American  Academy 

The  Oxidases  and  Other  Oxygen  Catalysts  Concerned  in  Biological 
Oxidations. 

A  Study  of  the  Anatomy  of  Watsonins  (n.g.)  IVatsoni  of  Man,  and  of  19 
Allied  Species  of  Mammalian  Trematode  Worms  of  the  Superfamily  Param- 
phistomoidea. 

Quantitative  Pharmacological  Studies :  Relative  Physiological  Activity 
of  Some  Commercial  Solutions  of  Epinephrin. 

The  Taxonomic  Value  of  the  Microscopic  Structure  of  the  Stigma!  Plates 
in  the  Tick  Genus  Dermaccntor. 

Digest  of  Comments  on  the  Pharmacopoeia  of  the  United  States  of 
America  (Eighth  Decennial  Revision)  and  the  National  Formulary  (Third 
Edition)  for  the  Calendar  Year  Ending  December  31,  1907. 

Studies  upon  Anaphylaxis  with  Special  Reference  to  the  Antibodies 
Concerned. 

Facts  and  Problems  of  Rabies. 

I.  The  Influence  of  Age  and  Temperature  on  the  Potency  of  Diphtheria 
Antitoxin.  II.  An  Organism  (Pseudomonas  protea)  Isolated  from  Water, 
Agglutinated  by  the  Serum  of  Typhoid  Fever  Patients.  III.  Some  Consid- 
erations on  Colorimetry,  and  a  New  Colorimeter.  IV.  A  Gas  Generator,  in 
Four  Forms,  for  Laboratory  and  Technical  Use. 

The  Solubilities  of  the  Pharmacopoeial  Organic  Acids  and  their  Salts. 

The  Bleaching  of  Flour  and  the  Effect  of  Nitrites  on  Certain  Medicinal 
Substances. 

The  Effect  of  a  Restricted  Diet  and  of  Various  Diets  upon  the  Resist- 
ance of  Animals  to  Certain  Poisons. 

A  Study  of  Melting  Point  Determinations  with  Special  Reference  to  the 
Melting  Point  Requirements  of  the  United  States  Pharmacopoeia. 

I.  Some  Known  and  Three  New  Endoparasitic  Trematodes  from  Ameri- 
can Fresh  Water  Fish.  II.  On  Some  New  Parasitic  Trematode  Worms  of 
the  Genus  Telorchis.     III.  A  New  Species  of  Athesmia  from  a  Monkey. 

I.  Report  of  an  Outbreak  of  Typhoid  Fever  at  Omaha,  Neb.  (1909- 
1910).  II.  The  Water  Supply  of  Williamson,  W.  Va.,  and  its  Relation  to 
an  Epidemic  of  Typhoid  Fever. 

The  Effects  of  a  Number  of  Derivatives  of  Choline  and  Analogous  Com- 
pounds on  the  Blood-Pressure. 

These  bulletins  represent  very  well  the  scope  and  activities  of 
the  Hygienic  Laboratory  in  relation  to  scientific  research.  But  in 
addition  there  have  been  published  in  the  medical  and  scientific 
literature,  or  placed  on  file  in  the  archives  of  the  bureau,  many  brief 
reports  and  papers  that  have  had  a  distinct  value  in  the  advance- 
ment of  public  health  administration. 

The  Hygienic  Laboratory  has  also  been  utilized  as  a  school  of 
instruction  for  officers  of  the  Public  Health  Service,  and  its  facili- 
ties have  been  extended  from  time  to  time  to  sanitary  officers  on 

(276) 


Scientific  Research  by  the  Public  Health  Service  33 

request  of  state  health  authorities.  By  this  means  the  sanitary 
corps  has  been  strengthened,  and  from  among  its  members  have 
been  developed  those  capable  of  conducting  independent  research. 
By  this  means  also  it  was  possible  to  inaugurate  scientific  investiga- 
tions in  connection  with  public  health  stations  already  established. 
Severe  outbreaks  of  the  great  epidemic  diseases  have  been  in- 
dications for  the  conduct  of  research  of  a  clinical  or  labora- 
tory nature  in  the  infected  localities.  By  this  means  special  studies 
of  smallpox  were  made  on  the  Mexican  frontier  in  1895 ;  yellow 
fever  was  studied  in  the  Southern  States,  and  plague  in  Honolulu, 
T.  H. ;  Seattle,  Wash.,  and  San  Francisco,  Oakland,  and  Los 
Angeles,  Cal. 

The  Federal  Laboratory  of  the  Pacific 

The  suppression  of  plague  in  a  community  is  closely  associated 
with  the  eradication  of  the  disease  among  rodents.  In  order,  there- 
fore, to  determine  the  extent  of  the  epizootic  among  these  animals 
daily  examinations  of  large  numbers  are  necessary,  and  there  has 
also  been  need  of  careful  studies  to  clear  away  the  mysteries  sur- 
rounding the  relationship  of  the  disease  in  man  and  animals. 

The  Federal  Plague  Laboratory  was  therefore  established  dur- 
ing the  first  plague  outbreak  in  San  Francisco,  and  has  been  an  im- 
portant agent  in  the  suppression  of  the  first  and  second  outbreaks 
of  the  disease.  Its  most  lasting  value,  however,  will  be  derived 
from  the  scientific  studies  conducted  therein  regarding  the  epidemi- 
ology of  plague  among  ground  squirrels  and  other  rodents.  Some 
of  the  published  reports  of  these  studies  are  as  follows : 

Plague  Infection  in  Rats. 

Organic  Diseases  of  the  Rat. 

Rodents  in  Relation  to  the  Transmission  of  Bubonic  Plague. 

Rodent  Extermination;  Rats  and  Mice. 

Rat-Proofing  as  an  Antiplague  Measure. 

Notes  on  Rat  Leprosy  and  on  the  Fate  of  Human  and  Rat  Lepra  Bacilli 
in  Flies. 

Experimental  Investigation  of  Biting  of  Man  by  Fleas  from  Rats  and 
Squirrels. 

Evidence  of  Plague  Infection  among  Ground  Squirrels. 

General  Observations  on  the  Bionomics  of  the  Rodent  and  Human  Fleas. 

As  an  additional  means  of  disseminating  information  regarding 
the  pathology  and  diagnosis  of  plague  in  rodents,  mounted  speci- 

(277) 


34  The  Annals  of  the  American  Academy 

mens  of  plague  tissues  were  prepared  and  furnished  to  over  one 
hundred  and  fifty  medical  colleges  and  models  illustrating  various 
phases  of  the  disease  made  and  exhibited  to  the  public. 

In  the  Federal  Laboratory  on  the  Pacific  careful  observations 
have  been  made  not  only  of  plague  lesions,  but  other  abnormalities 
among  rodents,  particularly  lavyless  growths.  The  exact  value  of 
this  work  can  not  yet  be  estimated,  but  in  view  of  the  stimulus  given 
to  the  study  of  cancer  by  the  recent  successful  transplantation  of 
tumors,  it  is  possible  that  careful  observations  of  these  abnormali- 
ties may  in  time  develop  additional  facts  that  will  have  some  bear- 
ing on  the  cancer  problem.  At  any  rate,  it  was  through  such  ob- 
servations that  a  leprosy-like  disease  of  rats  was  first  detected  on 
the  Pacific  Coast,  which  observation  is  of  particular  interest  to  those 
engaged  in  the  study  of  leprosy  in  man. 

While  the  above-mentioned  laboratory  was  established  only  in 
response  to  a  great  administrative  necessity,  and  therefore  limited 
in  its  scope,  there  are  cogent  reasons  why  it  should  be  enlarged  and 
devoted  to  the  solution  of  the  sanitary  problems  peculiar  to  the 
Pacific  Coast.  One  of  these  is  the  necessity  of  epidemiological 
studies  of  leprosy  and  certain  diseases  peculiar  to  the  Orient. 

The  Leprosy  Investigation  Station 

A  commission  was  appointed  in  1899  in  accordance  with  a 
provision  of  an  act  of  Congress  to  study  leprosy,  particularly  with 
reference  to  its  prevalence  in  the  United  States.  These  studies  de- 
veloped the  fact  that  there  were  no  less  than  two  hundred  and 
eighteen  cases  of  leprosy  located  in  twenty-one  states  at  the  time 
the  report  of  the  commission  was  made  in  1902,  and  indicated  that 
some  provision  should  be  made  for  the  national  care  of  lepers. 
More  important  still,  it  indicated  that  there  should  be  systematic 
studies  of  leprosy  with  the  view  to  determining  the  methods  of 
transmission  of  the  disease  and  the  improved  methods  of 
treatment. 

Congress  accordingly  provided  for  such  investigations  in  Ha- 
waii, and  appropriated  funds  for  the  establishment  of  a  leprosy 
investigation  station  on  the  island  of  Molokai.  Systematic  studies 
were  begun  in  1906,  and  the  results  are  recorded  in  thirteen  papers. 
The  titles  of  these  papers  are  as  follows: 

(278) 


Scientific  Research  by  the  Public  Health  Service  35 

The  Present  Status  of  the  Leprosy  Problem  in  Hawaii. 

The  Reaction  of  Lepers  to  Moro's  "Percutaneous"  Test. 

A  Note  Upon  the  Possibility  of  the  Mosquito  Acting  in  the  Transmis- 
sion of  Leprosy. 

Upon  the  Utility  of  the  Examination  of  the  Nose  and  the  Nasal  Secre- 
tions for  the  Detection  of  Incipient  Cases  of  Leprosy. 

A  Report  upon  the  Treatment  of  Six  Cases  of  Leprosy  with  Nastine 
(Deycke). 

Leprosy  in  the  United  States  of  America  in  1909. 

A  Statistical  Study  of  an  Endemic  Focus  of  Leprosy. 

A  Palliative  Treatment  for  Leprous  Rhinitis.  -*., 

Mosquitoes  in  Relation  to  the  ^Transmission  of  Leprosy. 

Flies  in  Relation  to  the  Transmission  of  Leprosy. 

Heredity  versus  Environment  in  Leprosy. 

Notes  on  the  Study  of  Histories  of  Lepers  from  the  Standpoint  of  Trans- 
mission. 

A  Contribution  to  the  Study  of  Rat  Leprosy. 

Early  in  the  work  it  was  recognized  that  the  solution  of  the 
leprosy  problem  was  to  be  sought  for  among  incipient  cases  and  in 
the  homes  of  the  lepers  themselves.  A  branch  laboratory  was  ac- 
cordingly established  at  the  Kalihi  Station  on  Oahu,  where  lepers 
are  brought  on  being  apprehended,  and  here  work  of  the  most 
important  character  is  being  prosecuted.  While  it  is  inadvisable  to 
anticipate  the  results  of  these  studies  before  publication,  it  is  per- 
tinent to  refer  to  the  successful  growth  of  the  leprosy  bacillus,  and 
the  important  bearing  this  achievement  will  have  on  the  subsequent 
steps  of  the  investigation.  In  fact  the  way  is  now  open  for  the 
production  of  a  therapeutic  vaccine  and  perhaps  an  antitoxic  serum. 

The  Laboratories  of  Marine  Hospitals  and  Quarantine  Stations 

Besides  the  above  laboratories  devoted  wholly  to  research, 
provision  is  made  at  certain  of  the  marine  hospitals  and  quarantine 
stations  for  making  public  health  investigations.  At  the  quaran- 
tine stations  such  studies  have  mostly  to  do  with  determining  the 
best  means  of  disinfection  and  perfecting  methods  for  their  appli- 
cation. In  addition,  extended  experiments  have  been  made  of  the 
life  history  of  mosquitoes,  the  culicidal  properties  of  gases  and  other 
subjects  specially  related  to  quarantine  practice. 

At  the  marine  hospitals  there  is  always  opportunity  for  clinical 
research,  and  in  some  instances  this  is  unexcelled  because  of  the 
character  of  the  patients  admitted  and  the  fact  that  they  come  from 

(279) 


36  The  Annals  of  the  American  Academy 

every  quarter  of  the  globe.  In  addition  these  stations  are  utilized 
as  public  health  stations  where  certain  experiments  can  be  long 
continued.  For  instance,  at  the  marine  hospital  at  Wilmington, 
N.  C,  investigations  are  now  being  made  of  soil  pollution  and  the 
best  methods  for  its  prevention;  a  question  the  solution  of  which 
must  have  an  important  bearing  on  the  improvement  of  rural  sani- 
tation. Because  of  their  location,  and  relation  to  the  public  health 
service,  these  stations  are  capable  of  becoming  the  recognized  cen- 
ters of  special  research,  and  with  adequate  authority  to  admit  for 
purposes  of  scientific  studies  cases  of  diseases  affecting  the  public 
health  there  would  be  provided  a  powerful  means  of  determining 
the  causes,  methods  of  transmission  and  prevention  of  such  dis- 
eases within  the  country. 

The  field  for  research  is  broad,  but  in  view  of  present  limita- 
tions as  to  funds,  the  investigations  to  be  undertaken  must  be  care- 
fully planned  and  the  work  directed  in  order  that  there  shall  not  be 
duplication  or  loss  of  energy.  It  was  accordingly  recognized  that 
a  central  office  was  necessary  that  would  keep  in  touch  with  the 
scientific  workers  and  relieve  them  of  certain  administrative  obliga- 
tions. This  was  accomplished  through  the  establishment  of  a  bu- 
reau division  of  scientific  research. 

Supervision  of  Viruses,  Serums  and  Toxins 

With  the  reorganization  of  the  Marine  Hospital  Service  into  a 
Bureau  of  Public  Health  in  1902,  a  division  of  scientific  research 
was  provided,  through  which  are  handled  the  administrative  matters 
connected  with  service  investigations. 

Special  work  of  a  statistical  character  is  also  carried  on  and 
the  results  published  from  time  to  time  in  the  form  of  Public  Health 
Bulletins. 

It  is  the  additional  duty  of  this  division  to  supervise  the  pub- 
lication of  all  scientific  reports,  except  the  "Public  Health  Reports," 
and  to  discharge  those  administrative  duties  connected  with  the 
enforcement  of  the  law  of  July  i,  1902,  regulating  the  propagation 
of  viruses,  serums  and  toxins  in  interstate  traffic.  This  law  requires 
that  all  viruses,  serums  and  toxins  offered  for  sale  in  interstate 
traffic  shall  be  propagated  and  prepared  only  in  establishments 
licensed  by  the  Secretary  of  the  Treasury.     Licenses  are  granted 

(280) 


Scientific  Research  by  the  Public  Health  Service.  37 

only  after  inspection  of  establishments  made  in  accordance  with 
regulations  issued  under  the  law,  and  examination  in  the  Hygienic 
Laboratory  of  products  for  which  license  is  desired.  Since  these 
biologic  products  are  intended  for  hypodermatic  injections,  their 
freedom  from  contamination  is  of  paramount  importance,  and  be- 
cause of  the  great  value  of  some  of  them  in  the  treatment  of  the 
diseases  for  which  they  are  intended,  it  is  essential  that  purity  and 
potency  should  be  assured.  The  adoption  of  standards,  therefore, 
became  necessary.  Standards  for  testing  the  strength  of  diphtheria 
antitoxin  and  tetanus  antitoxin  were  especially  needed,  and  investi- 
gations to  this  end  were  undertaken  and  continued  until  a  standard 
for  diphtheria  antitoxin  was  adopted  in  1905,  and  a  standard  for 
tetanus  antitoxin  devised  in  1906.  The  standard  units  are  prepared 
in  the  Hygienic  Laboratory  and  distributed  bi-monthly  to  all 
licensed  manufacturers  and  others  concerned,  and,  by  means  of  ex- 
aminations of  serums  on  the  market  from  time  to  time,  it  is  deter- 
mined whether  they  are  free  from  contamination  and  conform  to 
these  standards,  and  in  the  case  of  those  products  for  which  no 
standard  has  been  devised,  whether  contamination  is  present  or  not. 
It  is  evident  that  the  administration  of  the  law  regulating  the  propa- 
gation of  biologic  products  involves  a  large  amount  of  highly  tech- 
nical work  and  requires  investigations  in  the  broad  field  of  immu- 
nity. As  a  result  studies  of  anaphylaxis  in  relation  to  immunity 
have  been  continued  over  a  period  of  more  than  four  years  and 
stimulated  an  immense  amount  of  work  on  the  same  problem  in 
other  laboratories  throughout  the  world.  The  number  of  biologic 
preparations  intended  for  the  prevention  and  cure  of  diseases  of 
man  is  rapidly  increasing,  and  their  standardization  becomes  a 
matter  of  importance.  Investigations  with  this  end  in  view  there- 
fore comprise  one  of  the  most  important  activities  of  the  service  at 
the  present  time. 

An  inquiry  into  the  prevalence  of  rabies  during  1908  and  sub- 
sequent studies  of  antirabic  virus  led  to  the  preparation  of  that 
product  for  administration  at  the  Hygienic  Laboratory  and  its  dis- 
tribution for  the  use  of  state  health  authorities.  As  a  result,  this 
treatment  was  made  available  to  1,143  patients  from  April  25,  1908, 
to  June  30,  19 10,  and  the  problems  of  rabies  are  being  carefully 
investigated. 

(281) 


38  .         The  Annals  of  the  American  Academy 

Zoological  Investigations 

Beginning  with  the  discovery  of  the  Uncinaria  Americana  in 
1902,  studies  of  hookworm  disease  have  been  carried  on  with  great 
energy,  and  in  my  opinion  no  other  single  event  in  the  field  of  pre- 
ventive medicine  has  had  as  far-reaching  importance  to  the  people  of 
the  United  States  since  the  discovery  of  diphtheria  antitoxin.  The 
studies  already  made  have  not  only  accounted  for  a  large  amount 
of  invalidism  in  the  South  and  cleared  away  in  some  measure  the 
confusion  with  respect  to  several  diseases,  but  they  have  demon- 
strated the  methods  necessary  to  the  improvement  of  the  physical 
and  mental  vigor  of  the  people  of  an  important  section  of  the  coun- 
try. Zoological  studies  in  the  interest  of  the  public  health  are  es- 
pecially indicated  in  view  of  the  causal  relation  of  animal  parasites 
to  diseases  and  the  inffuence  of  insects  as  carriers  of  infection,  and 
represent  a  broad  field  of  activities  of  the  Public  Health  Service. 
Studies  of  a  number  of  subjects  are  now  in  progress,  and  the  re- 
sults of  those  completed  are  contained  in  bulletins  already  published. 

Pharmacologic  Research 

Authority  having  been  granted  in  190 1  for  laboratory  investi- 
gations of  matters  pertaining  to  the  public  health,  and  a  division  of 
pharmacology  in  the  Hygienic  Laboratory  having  been  authorized 
in  1902,  pharmacologic  studies  became  a  part  of  the  activities  of 
the  service.  Investigations  of  organo-therapeutic  and  other  medici- 
nal preparations  were  inaugurated  and  have  been  continued.  Di- 
gests of  comments  on  the  Pharmacopoeia  and  the  National  Formu- 
lary are  compiled  regularly  and  published  for  use  in  connection 
with  revision  of  those  important  official  standards.  The  import- 
ance of  establishing  standards  of  strength  for  potent  drugs  has 
opened  up  a  wide  field  for  investigations ;  those  already  in  progress 
relating  to  epinephrin,  ergot  and  digitalis.  In  addition,  new  prep- 
arations are  being  made  from  time  to  time  and  studied  as  to  their 
therapeutic  value.  These  matters  also  involve  physiologic  consid- 
eration including  the  functions  of  the  ductless  gland. 

Recent  announcement  of  the  discovery  of  an  arsenic  prepara- 
tion reputed  to  have  marvelous  curative  properties  in  certain  pro- 
tozoal diseases  indicates  the  possibilities  of  pharmacologic  studies, 

(282) 


Scientific  Research  by  the  Public  Health  Service  39 

and  emphasizes  the  importance  of  their  continuance  under  official 
auspices. 

Chemical  Studies 

As  previously  stated,  provision  was  made  for  a  division  of 
chemistry  in  the  Hygienic  Laboratory,  wherein  have  been  con- 
ducted systematic  studies  of  water  and  milk  in  relation  to  the  public 
health.  The  action  of  ferments  and  the  chemistry  of  the  blood  have 
also  been  considered  and  the  results  published  as  bulletins.  Other 
studies  made  and  the  bearing  of  chemical  questions  on  the  public 
health  emphasize  the  scope  of  this  division,  which  was  but  recently 
organized  and  which  is  destined  to  fulfil  an  important  function  in 
public  health  work. 

Epidemiological  Investigations 

The  foregoing  organization  for  research  and  the  facilities  for 
carrying  it  on  have  resulted  in  the  co-operation  of  several  of  the 
divisions  along  epidemiologic  lines. 

Typhoid  fever  has  been  the  subject  of  continuous  studies  for 
over  four  and  one-half  years,  and  has  engaged  the  attention  at  times 
of  three  of  th?  divisions  of  the  Hygienic  Laboratory,  Aside  from 
tuberculosis  there  is  no  infectious  disease  that  is  more  nearly  uni- 
versal in  the  United  States,  and  none  deserving  more  earnest  study 
from  both  health  and  economic  standpoints. 

Systematic  studies  into  the  origin  and  prevalence  of  typhoid 
fever  were  begun  in  the  District  of  Columbia  in  1906,  and  carried 
on  there  during  four  seasons.  A  large  amount  of  accurate  data  was 
accumulated  and  published,  throwing  light  on  the  local  problem  and 
having  general  application  to  typhoid  fever  problems  in  other  sec- 
tions of  the  country.  Studies  of  the  disease  have  also  been  made 
by  the  service  in  five  widely  separated  states ;  and  the  facts  elicited 
while  clearing  up  local  problems  have  indicated  the  necessity  of 
like  studies  in  other  sections  of  the  country. 

The  manifold  avenues  through  which  typhoid  fever  spreads 
involves  a  wide  field  for  investigations.  The  studies  are  necessarily 
made  in  the  presence  of  outbreaks  and  include  many  lines,  such  as 
the  purity  of  milk  supplies,  the  extent  of  the  pollution  of  water  sup- 
plies, the  role  of  insects  as  carriers  of  infection,  the  percentage  of 
bacillus  carriers  among  the  population  in  different  sections  of  the 

(283) 


40  The  Annals  of  the  American  Academy 

country,  and  the  influence  of  contact  as  a  factor  in  the  propagation 
of  the  disease. 

A  large  amount  of  data  is  necessary  on  all  phases  of  the  typhoid 
fever  problem  in  order  that  the  deductions  to  be  drawn  may  be  of 
general  application.  There  is  also  necessity  for  a  better  under- 
standing on  the  part  of  the  people  as  to  the  known  facts  regarding 
preventive  measures,  and  this  comprises  one  of  the  most  important 
duties  of  the  Public  Health  Service  in  relation  to  the  control  of  the 
disease. 

Similar  statements  apply  also  to  other  preventable  diseases, 
such  as  pellagra  and  poliomyelitis,  which  are  being  made  subjects 
of  special  study.  There  is  authority  for  their  investigation  in  the 
laboratory,  and  the  extent  of  such  activities  is  limited  only  by  the 
available  appropriations.  Since,  however,  the  .prevention  of  dis- 
eases involves  improved  sanitary  methods  and  devices,  additional 
authority  must  be  had  for  studies  outside  the  Hygienic  Laboratory 
better  to  cover  the  field. 

From  the  brief  outline  presented  it  is  apparent  that  the  ac- 
tivities of  the  Public  Health  Service  relate  to  many  subjects,  and 
that  their  enlargement,  in  so  far  as  relates  to  research,  is  almost 
wholly  dependent  on  additional  authority  to  be  obtained. 

Because  of  our  form  of  government  and  the  consequent  di- 
vision of  responsibility  among  national,  state  and  municipal  agen- 
cies in  respect  to  the  public  health,  two  of  the  most  important  duties 
of  the  federal  government  are,  in  my  opinion,  scientific  research 
and  the  collection  and  dissemination  of  useful  information.  The 
object  of  the  present  public  health  movement  is  to  prevent  disease 
and  to  prolong  life  and  make  it  more  productive.  This  can  be  ac- 
complished largely  through  universal  acceptance  and  observance  of 
hygienic  principles  by  the  people. 

Legal  restrictions  are  necessary  and  there  will  undoubtedly  be 
indication  for  others  in  the  interest  of  the  public  health,  but  when 
adopted  they  will  of  necessity  be  enforced  by  the  states,  except  in 
those  instances  involving  interstate  relations.  But  the  federal  gov- 
ernment will  perform  an  important  service  in  bringing  about  uni- 
formity of  action  by  rendering  accessible  the  facts  on  which  such 
action  is  based. 

In  the  German  Empire  a  wise  policy  has  had  such  an  eflfect. 

(284) 


Scientific  Research  by  the  Public  Health  Service  41 

In  that  country  the  confederation  of  states  and  free  cities  is  looser 
than  in  the  United  States  ;  yet  governmental  scientific  research  in  the 
interest  of  the  public  health  has  been  most  productive,  and  the  large 
amount  of  valuable  statistics  available  was  collected  through  volun- 
tary co-operation  of  those  states  and  cities.  Theoretically  the  im- 
perial government  can  exercise  police  powers  in  a  state  for  the 
suppression  of  outbreaks  of  disease,  but  so  far  as  known  this  has  not 
been  done  nor  has  there  been  any  necessity  for  doing  so.  The 
experience  of  the  German  Empire  is  of  value  in  considering  the 
development  of  future  public  health  activities  in  our  country, 
especially  as  relates  to  scientific  research.  The  organization  for 
such  work  on  the  part  of  the  federal  government  is  well  founded, 
and  in  certain  respects  broader  than  in  other  countries.  With 
proper  development  it  should  in  time  be  as  productive  of  results  as 
any  national  agency. 


(285) 


THE  CENSUS  AND  THE  PUBLIC  HEALTH  MOVEMENT 


By  Cressy  L.  Wilbur, 
Chief  Statistician  of  Vital  Statistics,  Bureau  of  the  Census,  Washington,  D.  C. 


The  Bureau  of  the  Census,  which  is  one  of  the  bureaus  con- 
stituting the  Department  of  Commerce  and  Labor,  is  the  only  Fed- 
eral agency  that  deals  with  the  collection,  compilation  and  publica- 
tion of  general  vital  statistics  for  the  United  States. 

Through  its  division  of  vital  statistics — one  of  the  five 
divisions  into  which  it  is  at  present  organized — it  receives  returns 
of  births  and  deaths  monthly  from  such  states  and  cities  as  afford 
registration  data  in  satisfactory  detail,  and  sufficiently  complete 
with  respect  to  the  total  number  registered  to  repay  compilation. 

The  other  divisions  of  the  Bureau  of  the  Census,  as  consti- 
tuted for  the  three  years  of  the  "decennial  census  period"  ending 
June  30,  1912,  during  which  time  the  thirteenth  census  (1910)  is 
to  be  taken  and  its  results  published,  are  those  of  population,  agri- 
culture, manufactures,  and  methods  and  results.  One  of  these, 
the  Division  of  Population,  bears  an  especially  important  relation 
to  vital  statistics,  because  its  data,  the  statement  of  the  number  of 
persons  living  in  every  portion  of  the  United  States,  with  full 
details  of  sex,  age,  color,  civil  condition,  nationality,  parent  nation- 
ality, etc.,  form  the  indispensable  basis  with  which  the  returns  of 
births  and  deaths  derived  from  registration  records  must  be  com- 
pared in  order  to  compute  vital  rates. 

Importance  of  an  Accurate  Census  of  Population 

Hence,  first  of  all  in  the  activity  of  the  Bureau  of  the  Census 
relating  to  vital  statistics,  we  must  place  an  absolutely  correct  cen- 
sus of  population,  or  at  least  as  correct  a  census  as  ordinary  human 
agencies  operating  with  the  best  means  at  our  disposal  and  with 
honesty  of  purpose  and  method  may  be  able  to  obtain. 

The  recent  census,  taken  as  of  April  15,  1910,  is  the  most 
perfect  and  complete  census  that  has  yet  been  taken  in  the  history 

(286) 


The  Census  and  the  Public  Health  Movement  43 

of  the  Federal  Government.  The  fact  that  the  census  has  refused 
to  accept  padded  returns  from  certain  locaHties  may  have  cast 
doubt  in  the  minds  of  some  upon  the  correctness  of  the  census  as  a 
whole.  It  is  very  unfortunate,  indeed,  that  local  dishonesty,  which 
has  probably  existed  to  some  extent  in  previous  censuses,  should 
thus  cast  a  stigma  upon  the  work,  but  it  is  evident  that  no  better 
method  for  the  correction  of  such  abuses  is  available  than  full 
publicity  and  prosecution  of  the  individual  offenders.  Otherwise 
the  erroneous  returns  of  population  may  be  used  for  years  to  come 
as  the  basis  of  lying  rates,  which  the  officials  printing  them  should 
know  to  be  fraudulent,  although  they  may  claim — in  the  absence 
of  full  investigation  and  rejection  on  the  part  of  the  Government — 
as  in  an  advertising  pamphlet  that  recently  came  to  my  attention 

that  "Government  statistics  place among  the  healthiest 

cities  in  the  United  States."  So  "Government  statistics,"  based 
on  a  dishonest  enumeration  of  population,  did ;  and  it  is  a  satisfac- 
tion, indeed,  that  a  correct  count  of  population  in  1910  relegates 
this  city  to  its  proper  position  with  respect  to  mortality  rates. 

Certain  cities  for  which  the  populations  as  first  returned  have 
proved  to  be  grossly  overstated  should  be  thankful  that  correct 
rates  will  be  available  for  1910  and  subsequent  years,  and  that 
their  figures  will  not  be  discredited  by  extravagantly  low  rates  of 
mortality  such  as  carry  conviction  to  no  one  competent  to  judge 
of  vital  statistics.  Aside  from  its  dishonesty,  the  policy  of  over- 
statement of  population  is  a  short-sighted  one,  because  the  next 
census  must  likewise  be  padded,  and  in  the  same  proportion,  which 
means  in  greater  numerical  amount,  unless  a  falling  off  in  the  rate 
of  growth  is  to  appear.  And  in  passing  from  a  dishonest  to  an 
honest  census,  an  increasing  rate  of  mortality  might  be  shown  for 
intercensal  years,  when  the  actual  rate  was  constant  or  decreasing, 
so  that  an  effective  sanitary  administration  might  be  discredited 
by  erroneous  rates  based  upon  false  population  returns  made  years 
before.  There  are  ways,  known  to  certain  health  offices,  by  which 
even  a  handicap  of  this  kind  could  be  temporarily  overcome,  and 
by  rejecting  various  classes  of  deaths,  with  increasing  latitude  from 
year  to  year,  the  figures  can  be  "juggled"  to  show  almost  any 
desired  reduction  of  mortality  as  a  whole  or  for  certain  diseases. 
But  there  will  be  less  of  this  done  in  future,  because  the  registration 
oflficials  of  the  United  States  have  now  organized  and  adopted  cer- 

(287) 


44  The  Annals  of  the  American  Academy 

tain  standard  "Rules  of  Statistical  Practice,"  which  are  approved 
and  enforced  by  the  Bureau  of  the  Census  in  the  transcripts  col- 
lected by  it  and  compiled  for  its  annual  reports  on  mortality  sta- 
tistics,  so  that  a  sharp  discrepancy  will  at  once  appear  between  the 
census  figures  and  those  of  any  office  that  fails  to  make  a  complete 
and  correct  compilation. 

A  correct  enumeration  of  population  every  ten  years  is  thus 
seen  to  be  the  absolutely  indispensable  basis  of  correct  vital  sta- 
tistics for  the  United  States.  In  fact,  this  period  is  too  long,  be- 
cause it  is  impossible  to  interpolate,  with  entirely  satisfactory  pre- 
cision, estimated  populations  for  the  intercensal  years  that  lie 
between  the  decennial  enumerations.  This  is  true  for  all  countries, 
but  is  especially  true  for  the  United  States,  with  its  rapid  and  un- 
usual growth  in  certain  localities,  so  that  it  is  very  much  to  be 
desired  that  an  interdecennial  enumeration  should  be  taken.  This 
is  already  provided  for  in  some  States,  and  the  practice  should  be 
made  general. 

Collection  of  Vital  Statistics  by  the  Census 

Coming  now  to  the  more  immediate  activity  of  the  Bureau  of 
the  Census  with  respect  to  the  subject  of  vital  statistics,  it  is  a  some- 
what astonishing  fact  that  the  Federal  Government  has  no  authority, 
under  the  Constitution  of  the  United  States,  directly  to  collect  vital 
statistics,  through  the  absolutely  necessary  means  of  registration  of 
births  and  deaths,  except  in  the  District  of  Columbia,  which  is 
entirely  under  Federal  control. 

Provision  was  made  for  the  first  census  (1790)  of  the  United 
States  by  the  Constitution  so  that  "representatives  and  direct  taxes 
shall  be  apportioned  among  the  several  States  which  may  be  in- 
cluded within  this  Union,  according  to  their  respective  numbers," 
and  further  enumerations  were  authorized  "within  every  subse- 
quent term  of  ten  years."  Although  the  word  "census"  does  not 
appear  in  the  constitutional  provision  (Article  I,  Section  2),  nor 
in  the  organic  act  providing  for  the  first  enumeration  of  population 
of  the  United  States,  there  was  thus  instituted  the  line  of  decennial 
censuses  which  have  now  been  taken  regularly  for  one  hundred  and 
twenty  years.  The  United  States  was  the  first  country  in  the 
world  to  provide  for  a  regular  periodical  enumeration  of  inhabitants, 
dn  example  which  has  now  been  followed  by  practically  all  civil- 

(288) 


The  Census  and  the  Public  Health  Movement  45 

ized  nations.  It  may  be  said,  indeed,  that  the  establishment  of  a 
regular  census  of  population  and  the  registration  of  vital  statistics 
are  the  first  steps  taken  in  placing  a  country  upon  the  plane  of 
modern  civilization.  While  the  United  States  led  the  world  with 
respect  to  the  census  of  population,  we  still  rank  with  the  most 
unprogressive  and  semi-civilized  countries  as  concerns  the  registra- 
tion of  births  and  deaths. 

As  stated  in  the  work  from  which  some  of  the  preceding  facts 
have  been  taken,^  the  provision  authorizing  a  decennial  census  "was 
embodied  in  the  Constitution  for  political  purposes  wholly,  and 
with  no  thought  for  providing  for  any  systematic  collection  of  sta- 
tistical data  beyond  the  political  necessities  of  the  Government." 
There  was  certainly  no  thought  of  providing  a  basis  for  vital  sta- 
tistics, nor  of  furnishing  material  for  the  purpose  of  protecting  the 
public  health.  Indeed,  such  a  matter  as  the  "public  health"  was 
entirely  without  the  purview  of  the  fathers  of  the  republic,  and  lay 
unrevealed  in  the  womb  of  the  future.  Not  until  the  awakening 
to  the  unnecessary  destruction  of  human  lives  and  the  beginning 
of  modern  sanitation  in  England  in  the  40's  of  the  last  century, 
based  upon  the  data  collected  by  the  first  modern  registration  law 
for  vital  statistics,  namely,  that  passed  for  England  and  Wales  in 
1836,  did  it  enter  into  the  conception  of  the  State  that  one  of  its 
chief  functions  was  the  protection  of  the  lives  of  its  inhabitants 
not  only  from  foreign  foes,  but  also  from  the  more  deadly  and  dan- 
gerous enemies  of  disease.  Even  to-day  the  sole  authority  that  the 
United  States  Public  Health  and  Marine  Hospital  Service  attempts 
to  exercise  within  the  United  States,  aside  from  its  peculiar  func- 
tion as  related  to  the  medical  care  of  merchant  seaman  and  in 
cooperation  with  state  authorities  acting  under  state  constitutions 
that  provide  for  the  protection  of  the  health  of  States,  is  derived 
from  the  provision  of  the  Constitution  permitting  the  Federal  Gov- 
ernment to  regulate  interstate  commerce.  Only  as  epidemic  dis- 
eases interfere  with  the  interstate  movement  of  property,  no  matter 
how  inefficient  may  be  the  state  control  of  a  dangerous  disease,  can 
the  Federal  Government  intervene  to  protect  the  people  of  the 
United   States. 

Such  a  condition  might  well  be  considered  intolerable,  were  it 

» History  and  Growth  of  the  United  States  Census,   1790-1890,  by  Carroll  D. 
Wright  and  William  C.  Hunt. 

(289) 


46  The  Annals  of  the  American  Academy 

not  largely  ameliorated  by  the  cordial  cooperation  of  state  authori- 
ties in  times  of  danger,  as  when  yellow  fever  menaced  New 
Orleans  and  the  plague  was  to  be  stamped  out  in  San  Francisco, 
with  the  United  States  Public  Health  and  Marine  Hospital  Serv- 
ice. Such  cordial  cooperation  exists  also  with  respect  to  the 
registration  of  vital  statistics,  and  much  of  the  progress  made  in 
recent  years  is  due  to  the  harmonious  action  of  the  state  and  city 
authorities  with  the  Bureau  of  the  Census.  It  is  possible  that 
stronger  and  more  direct  agencies,  were  they  permissible,  would 
accomplish  little  more,  because  an  essential  requirement  in  the  estab- 
lishment of  effective  registration  work  under  our  form  of  govern- 
ment is  that  the  people  shall  understand  its  importance,  and  there- 
fore support  it  in  operation.  A  law  without  moral  support  cannot 
be  thoroughly  enforced  in  the  United  States. 

One  of  the  first  results  apparent  from  the  national  registra- 
tion law  that  went  into  effect  in  England  in  1837  was  the  light  cast 
upon  the  conditions  affecting  mortality.  We  may  justly  consider 
the  modern  public  health  movement,  that  has  now  become  perhaps 
the  most  characteristic  feature  of  the  twentieth  century,  a  neces- 
sary consequence  of  the  attention  given  to  mortality  statistics.  In 
the  First  Annual  Report  of  the  Registrar-General  of  Births,  Deaths 
and  Marriages  in  England,  London,  1839,  we  are  struck  at  once 
with  the  practical  sanitary  importance  of  the  deductions  made  by 
the  editor.  Dr.  William  Farr,  who  at  once  placed  the  work  upon  the 
firm  basis,  from  which,  through  the  successive  annual  reports  for 
over  seventy  years,  it  has  not  departed.  As  an  immediate  result  of 
such  statistical  information,  which  replaced  the  old  haphazard 
guesses  and  inferences  derived  from  the  limited  scope  of  bills  of 
mortality,  the  progressive  movement  for  the  improvement  of  pub- 
lic health  was  begun,  which  is  now  proceeding  in  almost  every  coun- 
try of  the  world  with  yearly  accelerated  pace.  The  impulse  was 
rapidly  transmitted  to  this  side  of  the  Atlantic  long  before  any 
state  or  even  city  boards  of  health  were  established.  Its  results 
are  recorded  in  the  annual  registration  reports  of  Massachusetts, 
prepared  under  the  Act  of  March  3,  1842.  The  best  medical  talent 
and  the  most  progressive  minds  appear  to  have  been  enlisted  by  the 
Secretaries  of  State  of  Massachusetts  for  the  preparation  of  these 
early  Massachusetts  reports. 

The  almost  unanimous  opinion  of  practical  public  health  work- 

(290) 


The  Census  and  the  Public  Health  Movement  47 

ers  in  all  countries  is  that  accurate  vital  statistics  are  the  absolutely 
necessary  foundation  of  effective  public  health  work.  What  is  the 
reason,  then,  after  recognition  of  this  fact,  that  vital  statistics  are 
not  to-day  as  completely  and  accurately  registered  in  the  United 
States  as  in  most  other  countries? 

History  of  Efforts  of  the  Census  to  Collect  Vital  Statistics 

As  a  result  of  the  establishment  of  early  systems  of  registra- 
tion, first  in  Massachusetts,  and  then  in  other  states,  much  interest 
was  aroused  on  the  subject  in  various  parts  of  the  country,  and 
provision  was  made  in  the  act  for  the  seventh  census  (1850)  for 
the  inclusion  of  the  subject  of  mortality  statistics. 

The  report  clearly  indicated  the  difficulty,  which  is  an  abso- 
lutely insuperable  one,  of  collecting  vital  statistics  by  enumera- 
tion after  the  close  of  the  year  to  which  the  data  relate.  No 
accurate  statistics  can  be  obtained  in  this  manner,  and  the  suc- 
cessive experiences  of  the  eighth  census  (i860),  ninth  census 
(1870),  tenth  census  (1880),  eleventh  census  (1890),  and  twelfth 
census  (1900),  only  served  to  confirm  the  opinion  expressed  in  this 
original  report  of  1850,  that  mortality  figures  based  upon  enumera- 
tors' returns  were  incomplete  and  mignt  be  misleading.  It  was  not 
until  the  thirteenth  census  (1910),  however,  that  the  method  of 
attempting  to  obtain  mortality  statistics  by  enumeration  of  deaths 
at  the  time  of  taking  the  general  census  of  population  was  entirely 
done  away  with. 

The  discarding  of  the  antiquated  and  pernicious  method  of 
enumerating  deaths  was  made  possible  by  the  extension  of  proper 
methods  of  registration.  Registration  of  vital  statistics  is  a 
method  sharply  distinctive  from  the  method  of  enumeration.  By 
registration  of  a  birth  or  death  is  meant  the  immediate  recording 
of  the  same.  That  is  to  say,  for  deaths  it  is  necessary  that  a  com- 
pulsory provision  of  law  be  enforced  that  no  human  body  shall  be 
interred,  removed  from  the  place  at  which  death  occurred,  or 
otherwise  disposed  of,  until  a  proper  legal  and  statistical  record  has 
been  made.  Such  a  provision  can  be  enforced  only  by  means  of  a 
compulsory  burial  or  removal  permit.  In  like  manner,,  complete 
birth  registration  depends  upon  prompt  reports  by  physicians  or 
midwives  not  over  ten  (10)  days  after  the  occurrence  of  the  birth, 
and  with  some  method  of  checking  failures  to  report.     For  both 

(291) 


48 


The  Annals  of  the  American  Academy 


^ 


(292) 


The  Census  and  the  Public  Health  Movement  49 

births    and    deaths    the    essential    condition    for    efficiency    is    the 
enforcement  of  the  law  by  means  of  the  penalties  therein  provided. 

Extension  of  the  Registration  Area 

The  foregoing  map  shows  the  growth  of  the  registration  area 
for  deaths  from  the  date  of  its  establishment  under  the  tenth 
census  (1880),  when  it  consisted  only  of  two  registration  States, 
Massachusetts  and  New  Jersey,  and  a  few  independent  registration 
cities,  with  an  aggregate  population  amounting  to  only  seventeen 
per  cent,  of  the  total  population  of  continental  United  States,  up 
to  the  present  time,  when  it  inclucles  something  over  one-half  of  the 
total  population  of  the  country. 

An  account  of  the  development  of  the  registration  area  may  be 
found  on  page  18  of  the  little  Physicians'  Pocket  Reference  to  the 
International  List  of  Causes  of  Death,  a  copy  of  which  has  been 
sent  to  every  physician  in  the  United  States,  to  medical  students, 
health  officers  of  states  and  cities,  and  local  registration  officials, 
and  which  will  be  sent  by  the  Director  of  the  Census  upon  request 
to  any  person  interested  in  the  movement  for  better  vital  statistics. 
It  illustrates  incidentally  a  most  important  feature  of  the  practical 
work  of  the  Bureau  of  the  Census  since  its  permanent  organization, 
namely,  missionary  work  for  the  extension  of  the  registration  area 
both  for  births  and  deaths.  The  crying  need  for  this  work  is  well 
expressed  by  the  introductory  paragraph  of  the  letter  of  trans- 
mittal of  the  Director  of  the  Census  to  the  Secretary  of  Commerce 
and  Labor : ^ 

It  seems  to  me  that  there  is  almost  nothing  more  important  in  the  entire 
field  of  statistics  than  vital  statistics,  because  of  their  direct  bearing  upon 
the  health  and  consequent  welfare  of  the  people.  It  certainly  is  both  strange 
and  shameful  that  the  United  States  should  be  so  far  behind  the  other  lead- 
ing countries  of  the  world  in  the  registration  of  deaths,  and  even  more  s»  in 
the  registration  of  births. 

Prior  to  the  organization  of  the  Bureau  of  the  Census  upon  a 
permanent  basis  in  1902,  it  was  imposssible  for  the  census  authori- 
ties to  make  any  systematic  effort  for  the  improvement  of  regis- 
tration methods.  The  law  providing  for  the  decennial  census  was 
usually  passed  at  the  latest  possible  moment,  and  it  was  then  neces- 

*  Physicians'  Pocket  Reference,  page  2. 

(293) 


50  The  Annals  of  the  American  Academy 

sary  to  organize  anew,  without  any  nucleus  of  a  permanent  staff, 
the  immense  force  necessary  for  the  taking  of  the  census  of  popu- 
lation, agriculture  and  manufactures,  within  a  brief  time.  Little,- 
if  any,  preliminary  attention  could  be  given  to  the  methods  of  col- 
lection of  the  data  of  vital  statistics,  nor  was  it  feasible  to  attempt 
to  introduce  uniform  methods.  Such  methods  could  only  be  adopted 
by  the  concerted  action  of  state  and  city  registration  officials,  and 
the  time  available  between  the  passage  of  a  decennial  census  law 
and  the  completion  of  the  census  was  too  brief  to  enable  such  an 
organization  to  be  completed.  Hence  the  work  of  the  Federal 
Census  in  mortality  statistics  had  comparatively  little  influence  on 
the  development  of  registration  methods  in  the  state  and  city  offices 
until  the  census  was  placed  upon  a  permanent  basis,  and  began  the 
compilation  of  annual,  not  merely  decennial,  reports  on  vital  statis- 
tics. At  once  a  new  era  began  and  the  possibility  of  uniform  and 
more  efficient  methods  was  suggested. 

One  of  the  first  steps  taken  by  the  Bureau  of  the  Census  in 
this  direction  was  the  adoption  of  the  international  classification 
of  causes  of  death,  which  had  already  been  accepted  by  the  leading 
state  and  city  offices  of  the  United  States,  as  the  system  to  be 
employed  in  the  annual  reports  on  mortality  statistics  beginning 
with  the  calendar  year  1900.  The  Bureau  of  the  Census  prepared 
a  Manual  of  the  International  Classification,  and  took  an  important 
part  in  the  second  decennial  revision  held  by  the  French  Govern- 
ment at  Paris  in  1909,  at  which  a  special  census  commission, 
appointed  under  the  first  public  act  passed  by  the  Sixty-first 
Congress,  was  present.  This  commission  was  appointed  by  the 
Director  of  the  Census,  and  contained  representatives  of  the  Com- 
mittees on  Nomenclature  and  Classification  of  Causes  of  Death  of 
the  American  Medical  Association  and  the  American  Public 
Health  Association,  the  latter  representing,  through  its  section  on 
vital  statistics,  the  organized  registration  officials  of  the  United 
States.  Attention  should  be  especially  called  to  the  latter  body. 
By  the  formation  of  a  section  on  vital  statistics  in  the  American 
Public  Health  Association,  an  organization  which,  from  its  history 
and  influence  on  practical  sanitation  in  the  United  States,  may  be 
taken  as  the  most  representative  body  of  sanitarians  in  this  coun- 
try, it  became  possible  for  the  first  time  to  deal  with  a  tangible 
body  of  statistical  workers,  with  power  to  act  and  to  carry  out 

(294) 


The  Census  and  the  Public  Health  Movement  51 

plans  for  the  improvement  of  vital  statistics  in  the  United  States. 
This  is  accomplished  by  means  of  rules  of  statistical  practice  (see 
Bulletin  108,  Mortality  Statistics,  1909,  pages  37  to  42),  which 
embody  definite  decisions  upon  important  statistical  methods,  and 
include,  among  other  recommendations,  the  use  of  the  United 
States  Standard  Certificate  of  Death,  as  revised  at  Richmond  in 
1909,  for  use  beginning  January  i,  1910,  a  primary  schedule  which 
places  the  collection  of  the  original  returns  of  death  upon  a  basis  of 
uniformity.  Uniform  rules  and  instructions  to  be  given  by  state 
and  local  registration  officials  are  provided,  so  that  physicians  and 
others  who  make  reports  upon  these  certificates  may  do  so  in  a 
uniform  and  comparable  manner.  The  use  of  such  a  schedule  is 
necessary  if  we  are  to  have  comparable  statistics  for  the  country 
as  a  whole,  and  it  may  be  considered  one  of  the  chief  results  ac- 
complished by  the  census  that  at  the  present  time  nearly  67,000,000 
of  the  population  of  the  country  are  represented  by  offices  that 
either  use  or  recommend  the  standard  blank. 

Approval  of  the  Congress  of  the  United  States 

Although  the  collection  of  vital  statistics  has  formed  a  part 
of  the  decennial  census  since  1850,  it  cannot  be  said  that  Congress 
or  the  Federal  Government  generally,  except  the  bureau  that  had 
the  matter  immediately  in  charge,  has  ever  taken  a  very  active  in- 
terest in  the  improvement  of  our  vital  statistics. 

The  general  interest  in  vital  statistics  that  was  awakened  in 
this  country  during  the  early  50's,  and  which  is  suggested  by  the 
list  of  states  that  passed  registration  laws,  was  utterly  dissipated 
by  the  intense  political  excitement  of  the  later  50's  and  by  the  civil 
war.  The  cause  of  registration  was  set  back  at  least  a  decade,  and 
perhaps  twenty  years,  and  it  was  not  until  the  later  6o's  and  during 
the  70's  that  attention  began  to  be  given  again  to  the  subject  of 
public  health. 

Many  state  boards  of  health  were  constituted  about  that  time, 
and  as  a  part  of  their  functions  the  subject  of  vital  statistics  was 
usually  included.  The  earlier  legislation  had  established  the  col- 
lection of  vital  statistics  under  some  officer  of  the  state  government, 
usually  the  Secretary  of  State.  There  were  then  no  state  boards 
of  health.     This  was  the  case  in  Massachusetts,  Michigan,  Ohio, 

(295) 


52  The  Annals  of  the  American  Academy 

Pennsylvania,  Vermont,  and  in  the  Southern   States  where  regis- 
tration laws  were  enacted. 

At  the  present  time  the  collection  of  vital  statistics  is  con- 
ducted by  the  state  sanitary  authorities  in  all  States  except  Massa- 
chusetts, Michigan,  Ohio,  and  South  Dakota.  Registration  work  is 
recognized  by  all  practical  sanitarians  as  the  absolutely  necessary 
basis  of  efficient  public  health  service,  but  it  is  not  always  certain 
that  our  state  boards  of  health,  as  at  present  constituted,  will  give 
more  effective  administration  of  registration  laws  than  if  they  were 
placed  under  some  other  department  of  the  state  government.  In 
all  cases,  of  course,  such  work  should  be  under  medical  direction, 
because  the  most  important  data  are  furnished  by  physicians  with 
whom  it  is  necessary  for  the  central  office  to  be  in  constant  corre- 
spondence. Such  work  is  medical  work,  and  it  is  very  desirable 
that  special  training  therein  should  be  given  in  our  advanced  medi- 
cal schools,  so  that  accomplished  vital  statisticians  may  be  available 
for  the  public  service,  in  addition  to  the  general  instruction  in  vital 
statistics  that  every  medical  student  should  receive.  Such  special 
knowledge  should  be  an  essential  part  of  work  for  the  degree  of 
Doctor  of  Public  Health  (D.  P.  H.).  In  the  practical  conduct  of 
registration  matters  the  state  boards  of  health  have  in  many  cases 
been  woefully  neglectful  of  their  duties  with  respect  to  registration 
simply  from  ignorance  of  its  importance  and  its  fundamental 
relation  to  their  work. 

The  general  approval  by  Congress  of  the  movement  for  bet- 
ter vital  statistics  was  shown  by  a  joint  resolution  adopted  by  Con- 
gress in  1903 : 

'•'That  the  Senate  and  House  of  Representatives  of  the  United 
States  hereby  expresses  approval  of  this  movement,  and  requests 
the  favorable  consideration  and  action  of  the  state  authorities,  to 
the  end  that  the  United  States  may  attain  a  complete  and  uniform 
system  of  registration." 

This  resolution  has  been  of  very  great  service  in  calling  the 
attention  of  governors  and  state  legislatures  to  the  importance  of 
registering  vital  statistics.  It  is  unfortunately  true,  however,  that 
Congress  has  neglected  to  secure  in  that  area  over  which  it  has 
sole  control,  namely,  the  District  of  Columbia,  that  uniform  and 
complete  system  of  registration  which  it  recommends  to  the  states. 
This  applies  more  especially  to  the  registration  of  births,  which  is 

(296) 


The  Census  and  the  Public  Health  Movement  53 

even  at  the  present  time  (1911)  admitted  by  the  District  Health 
Officer  to  be  incomplete,  and  appears  not  to  comprise  much  more 
than  ninety  per  cent,  of  the  births  that  actually  occur.  That  is  to 
say,  after  many  years  of  registration  in  the  city  of  Washington, 
whicli  is  coterminous  with  the  District  of  Columbia,  one  birth 
out  of  every  ten  that  occurs  may  fail  to  be  registered!  Congress 
has  ample  power  to  frame  a  law  that  will  secure  the  registration  of 
practically  every  birth  that  occurs  in  the  District  of  Columbia,  and 
it  has  ample  power  to  secure  the  enforcement  of  such  a  law  so  that 
it  might  serve  as  a  model  that  could  be  followed  by  other  cities 
of  the  United  States,  of  which  there  is  not  one  at  the  present  time 
with  complete  birth  registration. 

The  District  has  not  so  far  adopted  the  Standard  Certificate  of 
Death  which  has  been  such  a  great  factor  in  the  standardization  of 
the  mortality  statistics,  but  there  is  a  prospect,  with  the  cordial 
recommendation  of  the  District  Health  Officer,  that  use  of  the  stand- 
ard blank  will  be  provided  for  in  the  city  of  Washington  in  the  near 
future.  The  difficulty  in  securing  the  introduction  of  standard 
methods  and  of  complete  birth  registration  in  the  District  of  Colum- 
bia, under  the  direct  control  of  the  Federal  Government,  shows 
how  difficult  it  is  to  secure  the  adoption  and  enforcement  of  proper 
registration  laws  in  States,  some  of  which  are  sparsely  settled,  some 
of  which  have  a  very,  large  proportion  of  illiterate  population,  and 
many  counties  remote  from  railroad  communication,  when  the  de- 
sirable purposes  indicated  in  the  resolution  of  Congress  cannot  be 
carried  out  in  practice  in  the  Federal  District  itself. 

Obstacles  to  the  Extension  of  Proper  Registration  Methods  and 
Hoiv  They  Can  be  Overcome 

In  taking  a  general  view  of  the  progress  of  the  movement  for 
the  extension  of  adequate  registration  methods  in  the  United  States, 
the  question  arises  as  to  what  are  the  chief  obstacles  that  prevent 
the  general  introduction  and  enforcement  of  adequate  registration 
laws  so  that  the  United  States  may  become  at  once,  or  within  a 
very  short  time,  abreast  with  the  other  civilized  countries  of  the 
world  in  this  respect. 

The  first  and  most  important  obvious  difficulty  has  already 
been  pointed  out,  namely,  that  no  uniform  law  can  be  passed  for 

(297) 


54  The  Annals  of  the  American  Academy 

the  entire  country,  but  the  individual  and  harmonious  cooperation 
of  forty-eight  different  state  legislatures  and  of  Congress  itself  (for 
the  District  of  Columbia)  must  be  sought.  No  person  who  has 
followed  the  efforts  of  the  American  Bar  Association  and  the  Com- 
missioners on  Uniform  State  Laws  will  fail  to  recognize  the  great 
difficulties  in  securing  the  enactment  by  the  several  States  of  uni- 
form laws  respecting  some  comparatively  simple  matters  of  legal 
procedure.  When  we  consider  the  inherent  difficulties  of  enforcing 
a  registration  law  in  a  state  that  has  never  had  legislation  on  this 
subject,  and  in  which  undertakers  and  other  persons  are  accus- 
tomed to  dispose  of  the  bodies  of  the  dead  without  let  or  hindrance 
from  legal  authority,  it  will  rather  be  a  matter  of  surprise  that  so 
many  states  have  adopted,  within  the  last  ten  years,  laws  for  the 
registration  of  vital  statistics  that  are  substantially  identical  in  prin- 
ciple, and  in  many  cases  in  wording,  with  the  model  law.  At  the 
present  time  the  movement  for  the  introduction  of  uniform  regis- 
tration laws  has  met  with  more  actual  success  than  any  other  move- 
ment of  equal  scope  for  uniform  legislation. 

It  is  easy  to  secure  the  passage  of  registration  laws  in  com- 
parison with  the  difficulty  of  securing  thorough  enforcement  of 
them  when  passed.  The  duty  of  enforcing  such  laws  has  been 
largely  entrusted  to  the  state  boards  of  health.  These  bodies  are 
composed  mostly  of  physicians,  who  are  appointed,  in  many  in- 
stances, on  account  of  their  political  prominence  rather  than  be- 
cause of  any  special  knowledge  or  education  in  public  health 
methods.  Some  of  the  members  of  such  boards  may  be  entirely 
ignorant  of  the  importance  and  necessary  principles  of  effective 
registration,  and  even  the  executive  officers,  who  are  usually  the 
secretaries  of  the  state  boards  of  health,  may  enter  upon  the  prac- 
tical work  of  enforcing  a  state  registration  law  without  any  pre- 
vious knowledge  or  training  whatever  in  vital  statistics.  It  is  re- 
markable and  very  fortunate  that  some  public  health  officers,  both 
of  States  and  cities,  have  taken  up  the  subject  with  interest,  devel- 
oped it  with  enthusiasm,  and  have  done  their  best  under  existing 
conditions  to  secure  enforcement  of  registration  laws.  It  is  easy  to 
see,  however,  that  when  a  test  case  arises  and  the  state  registrar 
undertakes  to  enforce  the  penalty  of  the  law,  that  he  may  be  ham- 
pered by  the  appeal  of  the  delinquent  individual,  who  has  violated 
the  law  and  who  ought  to  be  punished,  to  some  members  of  the 

(298) 


The  Census  and  the  Public  Health  Movement  55 

board  or  to  political  authorities,  and  as  a  result  thereof  the  law  may 
practically  be  nullified  and  remain  unenforced. 

The  failure  to  enforce  registration  laws  is  almost  universal  in 
this  country  with  respect  to  births.  In  only  one  State  in  the  Union 
(Pennsylvania)  has  there  been  any  continued  and  persistent  effort, 
on  a  state-wide  basis,  to  enforce  the  law  requiring  physicians  and 
midwives  to  report  all  births.  The  effort  has  been  attended  with 
marked  success,  and  it  is  hoped  that  the  example  will  be  followed 
by  other  States.  Even  our  largest  and  most  densely  populated 
States  are  delinquent  in  this  respect,  and  it  has  been  found  under 
some  registration  laws  that  the  delinquency  was  greater  in  the  cities 
than  in  the  rural  districts.  Until  within  a  few  months  no  effort 
has  been  made  to  secure  complete  registration  of  births  by  sys- 
tematic enforcement  of  the  penalty  of  the  law  in  even  the  largest 
city  of  the  United  States  and  the  second  largest  city  in  the  world. 
The  first  recommendation  of  the  Advisory  Board,  recently  ap- 
pointed by  Commissioner  Lederle  to  consider  the  vital  statistics  of 
New  York  City,  was  as  follows : 

The  most  important  improvement  which  it  is  now  ready  to  urge  is  the 
adoption  of  the  following  means  for  securing  the  thorough  registration  of  all 
births : 

1.  Verification  of  the  birth  registration  of  every  infant  dying  under  one 
year  of  age  in  order  to  detect  omissions. 

2.  Strict  enforcement  of  the  law  providing  a  penalty  for  an  omission  to 
record  a  birth  in  every  case  thus  brought  to  light. 

This  recommendation  was  at  once  adopted  by  the  Board  of 
Health,  a  number  of  prosecutions  have  been  conducted,  fines  col- 
lected, and  it  is  likely  that  a  beginning  has  been  made  for  more 
thorough  and  complete  municipal  registration  of  births  in  this 
country. 

The  great  difficulty  in  securing  complete  birth  registration, 
which  can  only  be  accomplished  by  the  enforcement  of  the  law 
and  the  prosecution  of  the  comparatively  few  delinquents,  is  the 
fact  that  the  health  officers  are  dependent  upon  their  popularity 
with  the  medical  profession,  both  for  appointment  to  the  offices 
that  they  hoJd,  in  some  cases,  and  for  help  in  carrying  out  various 
methods  of  sanitation  which  they  deem  of  greater  importance  than 
the  thorough  registration  of  vital  statistics.  It  is  necessary,  there- 
fore, that  the  health  officials  of  the  United  States  be  educated  as  to 

(209) 


56  The  Annals  of  the  American  Academy 

the  fundamental  importance  of  correct  vital  statistics,  and  brought 
to  realize  the  fact  that  more  can  be  gained  in  the  long  run  by  estab- 
lishing a  sound  basis  of  registration  than  by  following  one  pet  fad 
this  year  and  another  the  next  without  any  correct  knowledge  as  to 
their  actual  results. 

The  paper  by  Samuel  H.  Adams,  in  "The  Survey"  for  the  week 
of  December  17,  1910,  entitled,  "Mixing  Hygiene  with  Politics," 
or  "Tomfoolery  with  Public  Health,"  indicates  how  dangerously  the 
various  functions  of  a  public  health  office,  whether  state  or  munici- 
pal, may  be  twisted  or  may  be  warped  to  the  public  detriment. 
This  is  especially  true  of  the  practical  conduct  of  vital  statistics, 
which  is  often  relegated  to  an  untrained  and  totally  incapable  per- 
son. The  resulting  worthless  data  may  then  be  used  by  an  equally 
untrained  health  officer,  so  that  the  public  and  press  may  be  en- 
tirely deceived  as  to  the  actual  conditions.  No  help  can  be  ex- 
pected from  services  of  this  character  in  the  thorough  enforcement 
of  registration  laws,  because  such  thorough  enforcement  will  tend 
to  disprove  the  fallacious  data  and  conclusions  presented. 

An  effort  has  been  made  to  improve  the  general  condition  of 
vital  statistics  in  the  United  States  by  building  up  an  effective  or- 
ganization of  registration  officials,  and  by  so  doing  to  improve  the 
morale  of  the  service,  and  its  standing  as  a  necessary  practical 
division  of  public  health  service.  The  attempt  has  been  to  some 
extent  successful,  and  the  rules  of  statistical  practice  have  already 
justified  themselves  in  practical  use.  Some  registration  officials  will 
continue  to  neglect  or  ignore  them,  and  there  is,  of  course,  no  com- 
pulsion for  their  use,  except  through  the  general  education  of  pub- 
lic and  statistical  opinion,  so  that  the  worthlessness  of  some  of  our 
present  municipal  reports  will  cause  a  demand  for  their  immediate 
abolition  or  reform.  It  is,  indeed,  only  by  building  up  public  and 
professional  sentiment  by  continually  pointing  out  the  importance 
of  accurate  registration  and  by  teaching  the  public  generally,  and  the 
medical  profession  more  particularly,  to  condemn  lax  and  ineffi- 
cient methods,  that  marked  improvement  can  be  secured  in  the 
United  States  under  our  present  conditions.  The  hearty  coopera- 
tion of  the  American  Medical  Association,  the  American  Public 
Health  Association,  the  American  Federation  of  Labor,  and  the 
beginning  cooperation  of  the  American  Federation  of  Women's 
Clubs,  are  significant  of  the  commencement  of  better  things. 

(300) 


The  Census  and  the  Public  Health  Movement  57 

The  census  has  been  for  many  years  as  the  voice  of  one  cry- 
ing in  the  wilderness,  and  its  heretofore  neglected  appeals  are  only 
recently  beginning  to  bear  fruit  in  effective  and  enforced  legisla- 
tion. It  will  be  many  years  to  come,  however,  at  the  present  rate 
of  progress,  before  we  can  expect  complete  registration  of  vital  sta- 
tistics, including  both  births  and  deaths,  for  the  entire  United 
States.  Not  only  the  nations  of  Western  Europe  have  long  sur- 
passed us  in  this  respect,  but  also  the  nations  of  the  Orient  may 
perhaps  do  so.  Japan  has  maintained  for  many  years  most  excel- 
lent reports  on  the  movement  of  population  and  statistics  of  causes 
of  death  embracing  the  entire  empire.  These  were  established  very 
soon  after  the  adoption  of  the  most  important  methods  of  western 
civilization,  and  the  annual  reports  surpass  anything  that  will  be  pos- 
sible for  the  United  States  at  the  present  rate  of  progress  for  half  a 
century  to  come.  China  has  just  taken  its  first  census,  and  very 
likely  will  proceed  to  the  establishment  of  a  registration  system.  The 
new  government  of  Turkey  will  doubtless  proceed  to  remove  the 
reproach  that  has  heretofore  rested  upon  that  country  in  this  respect. 

Perhaps  the  fundamental  difficulty  lying  at  the  root  of  our 
trouble  in  securing  accurate  vital  statistics  for  the  United  States, 
and,  more  particularly,  complete  statistics  of  births  even  for  cities 
where  registration  systems  have  been  established  for  many  years, 
is  the  American's  disregard  of  law.  Neglect  of  the  requirements 
of  law  would  seem  to  be  a  general  characteristic  of  the  American 
people,  and  the  failure  and  neglect  of  vital  statistics  laws  are  only 
special  cases.  How  can  one  expect  that  provisions  for  registra- 
tion of  births  and  deaths — the  importance  of  which  is  not  fully 
appreciated  even  by  some  physicians,  let  alone  the  people  generally, 
the  bar,  and  the  courts — should  be  enforced  when  crimes  of  active 
violence  may  not  be  punished?  Every  American  assumes,  in  his 
own  person,  to  be  a  court  of  last  resort,  so  far  "^s  passing  upon  the 
desirability  or  expediency  of  any  legal  provision  with  which  he  may 
come  into  conflict.  If  it  agrees  with  his  habits  of  thought  to  sub- 
mit to  the  law,  very  well;  and  if  not,  he  calmly  pronounces  it  "un- 
constitutional," and  it  practically  becomes  unconstitutional  for  him 
in  the  majority  of  cases,  because  the  officials  charged  with  the  en- 
forcement of  the  law  may  not  care  to  take  the  necessary  trouble,  or 
they  may  be  afraid  to  institute  the  necessary  legal  proceedings,  for 
the  imposition  of  a  fine  or  other  penalty. 

(301) 


58  The  Annals  of  the  American  Academy 

There  is  some  ground,  indeed,  for  the  disrespect  that  Ameri- 
can citizens  have  for  laws,  because  of  the  absurd  number  of 
statutes  that  are  ground  out  biennially  by  the  legislatures  of  the 
different  states.  Many  of  these  laws  are  ill  considered  and  not 
practical  in  operation.  Even  the  members  of  the  legislatures  that 
pass  them  do  not  expect  them  to  be  enforced.  The  United  States, 
in  spite  of  its  lack  of  effective  registration,  has  been  plastered  over 
with  laws  for  the  registration  of  vital  statistics,  many  of  which  could 
have  been  known  to  be  worthless  and  ineffective  before  the  gov- 
ernor's approval  was  secured,  just  as  well  as  after  years  of  ineffect- 
ive operation. 

It  has  been  one  of  the  most  important  tasks  of  the  Bureau  of 
the  Census  to  aid  in  the  proper  understanding  of  the  essential  prin- 
ciples that  should  govern  in  the  construction  of  registration  laws  for 
births  and  deaths,  to  advise  state  sanitary  officials  and  committees 
of  legislatures  in  regard  to  the  proper  construction  of  such  laws, 
and  to  deter,  as  far  as  possible,  the  passage  of  too  highly  special- 
ized and  comprehensive  laws  in  states  in  which  there  is  no  rea- 
sonable probability  of  securing  full  enforcement  and  satisfactory 
results.  Persons  who  become  interested  in  vital  statistics,  and  to 
whom  the  knowledge  of  the  lack  of  registration  in  their  own  states 
comes  for  the  first  time  with  the  effect  of  a  sudden  shock,  not  in- 
frequently desire  to  remedy  the  evil  all  at  once  by  "passing  a  law," 
and  expect  some  sort  of  a  miracle  to  be  worked  by  which,  with 
the  utmost  laxity  of  administration  and  with  perhaps  altogether 
inadequate  financial  provisions,  their  state  may  come  at  once  to  be 
accepted  as  a  part  of  the  registration  area. 

We  have  few  miracles  nowadays,  and  it  seems  better  and  more 
reasonable  to  institute  legislation  only  so  far  as  it  can  be  carried 
out.  This  advice,  however,  is  not  often  accepted,  and  usually  the 
cry  is  insistent  for  a  complete  law.  The  only  instances  in  which 
the  progressive  method  has  been  employed  are  in  the  cases  of 
Michigan,  which  passed  its  death  registration  law  in  1897,  and  later, 
in  1905,  after  the  law  for  the  immediate  registration  of  deaths  had 
proved  itself  a  success,  instituted  a  similar  law  for  the  immediate 
registration  of  births ;  and  the  State  of  North  Carolina,  the  first 
state  in  the  South  to  institute  a  modern  registration  law  in  1909, 
but  which,  in  the  wise  judgment  of  Dr.  Richard  H.  Lewis,  was  re- 
stricted to  the  complete  registration  of  deaths,  by  burial  permits, 

(302) 


The  Census  and  the  Public  Health  Movement  59 

in  municipalities  of  i,cxx)  population  and  over,  with  a  provision 
making  the  mayor  responsible  under  penalty  for  thorough  enforce- 
ment of  the  law.  The  law  is  now  in  operation,  and  will  be  ex- 
tended to  cover  the  entire  state,  and  to  include  births,  just  as  soon 
as  the  results  justify  such  action. 

Hope  for  the  Future 

We  have  seen  how  many  obstacles  intervene  in  the  way  of 
bringing  the  United  States  to  the  position  occupied  by  other  coun- 
tries with  respect  to  the  recording  of  the  data  of  vital  statistics. 
There  is  a  brighter  prospect,  however,  in  the  awakening  public  in- 
terest and  the  special  attention  that  has  been  given  to  the  importance 
of  this  subject  as  the  fundamental  basis  of  the  conservation  of 
human  life  and  the  movement  for  a  national  Department  or  Bureau 
of  Public  Health. 

All  the  effort  for  better  health  administration  in  the  United 
States,  and  for  the  establishment  of  a  national  public  health  service, 
is  more  or  less  directly  an  effort  for  better  vital  statistics  in  the 
United  States.  This  is  true,  because  a  public  health  service, 
whether  of  a  city,  of  a  state,  or  of  a  nation,  is  a  cripple  without 
dependable  vital  data.  The  duty  of  such  a  national  public  health 
service  would  be  to  see  whether  more  could  be  done  than  has  been 
done  by  the  Bureau  of  the  Census  to  bring  about  the  complete  reg- 
istration of  vital  statistics  in  the  United  States,  under  a  uniform 
system,  and  so  related  to  the  Federal  service  that  the  results  might 
be  utilized  promptly  and  with  full  confidence.  Nevertheless,  in  all 
the  discussions  and  arguments  on  this  question,  including  the  out- 
line of  bills  for  the  organization  of  such  a  service,  little  practical 
attention  was  given  to  the  subject,  and  no  suggestions  whatever  were 
presented  as  to  any  means  by  which  better  registration  can  be 
obtained  in  the  United  States. 

The  same  neglect,  in  fact,  that  now  hampers  the  efforts  of  the 
state  and  city  offices  that  fail  to  make  use  of  their  vital  statistics, 
and  to  insist  on  the  thorough  enforcement  of  their  laws  seems  to 
attend  the  representations  made  with  respect  to  the  Federal  serv- 
ice. A  Federal  health  department  would  have  no  more  legal  au- 
thority to  register  births  and  deaths  directly  than  has  the  Bureau 
of  the  Census,  and  certainly  no  more  cordial  cooperation  could  be 
desired  than  has  been  given  by  the  state,  and  by  nearly  all  city  health 

(303) 


6o  The  Annals  of  the  American  Academy 

authorities  to  the  movement  for  better  and  more  comparable  vital 
statistics.  Perhaps  the  enthusiasm  attending  the  creation  of  a  new 
department  would  cause  some  additional  activity,  but  spasmodic  in- 
terest alone  will  not  cause  state  legislatures  to  enact,  and  state 
sanitary  authorities  to  enforce,  laws  that  Congress  itself  is  appar- 
ently unable  to  carry  out  for  the  District  of  Columbia.  Neverthe- 
less, I  believe  it  is  perfectly  practicable,  if  there  should  be  a  real 
demand  for  better  vital  statistics  and  if  Congress  should  be  actually 
aroused  to  the  importance  of  proper  registration,  to  institute  a  thor- 
oughly cooperative  registration  service  by  state  authority  for  the 
collection  of  the  data  under  Federal  supervision  for  the  precision 
of  methods  and  results,  that  could  be  made  to  cover  the  entire 
United  States  within  a  brief  period,  and  that  would  prove  practical 
and  effective  in  operation. 


C304) 


SOURCES  OF  INFORMATION  UPON  THE  PUBLIC 
HEALTH  MOVEMENT 


By  Robert  Emmet  Chaddock,  Ph.D., 
Assistant  Professor  in  Economics,  University  oi,  Pwinsylvania. 

Introduction 

Someone  has  called  vital  statistics  the  Cinderella  of  modem 
public  hygiene.  She  sits  in  the  chimney  corner  and  sifts  the  ashes 
of  dusty  figures,  while  her  proud  sisters.  Bacteriology  and  Preventive 
Medicine,  go  to  the  ball  and  talk  about  the  wonderful  things  they 
have  done.  In  the  absence  of  statistics  visionary  theories  are  set 
forth,  so  contradictory  that  scientific  reasoners  and  business  men 
give  little  attention  to  them.  We  know  social  facts  completely  when 
we  measure  them.  We  cannot  measure  social  facts  without  statistics. 
They  are  the  testing  instrument  for  theories  and  schemes  of  social 
reform;  they  show  us  where  to  look  for  the  causes  of  social  mal- 
adjustments; they  become  the  basis  of  the  great  preventive  cam- 
paign which  characterizes  the  movements  toward  social  betterment 
at  the  present  time.  Consequently,  the  quantitative  study  of  social 
phenomena  is  attracting  the  attention  of  an  increasing  number  of 
students  to-day. 

Sound  vital  statistics  are  the  necessary  basis  of  modern  sani-. 
tation  and  register  dearly  the  steps  in  the  campaign  against  pre- 
ventable diseases,  often  pointing  the  way  to  the  next  step.  They 
furnish  a  definite  measure  of  the  value  of  sanitary  improvements. 
Pittsburgh  spends  $5,000,000  on  a  new  filter  plant  and  the  death  rate 
from  typhoid  at  once  falls.  Havana  is  cleaned  up  by  the  United 
States  Government  and  the  yellow  fever  scourge  subsides.  Sta- 
tistics register  the  progress  of  medicine  and  surgery.  Antiseptic 
surgery  comes  into  use  and  the  death  rate  from  operations,  especially 
in  war,  declines  to  a  remarkable  degree.  Vital  statistics  furnish  the 
basis  of  an  approximate  estimate  of  national  health. 

In  the  present  paper  the  sources  of  statistical  data  will  be  dis- 
cussed and  criticised  from  the  point  of  view  of  their  accuracy  and 
completeness  in  the  United   States.     Some  comparison  of  public 

(305) 


62  The  Annals  of  the  American  Academy 

health  statistics  in  the  United  States  will  be  made  with  foreign  coun- 
tries. Caution  in  the  use  of  material  and  care  in  interpretation  will 
be  emphasized  by  the  presentation  of  concrete  examples  of  error. 
Finally,  some  of  the  problems  of  the  public  health  movement  upon 
which  statistics  may  throw  light  will  be  suggested  and  illustrated 
by  concrete  material. 

I.     Sources  of  Statistical  Information 
I.     The  United  States  Census  Reports  and  Bulletins 

The  United  States  is  far  behind  the  other  great  civilized  nations 
in  the  field  of  vital  statistics,  which  includes  a  record  of  deaths, 
births,  and  marriages — a  field  most  closely  touching  the  interests  of 
the  people  through  its  connection  with  public  health.  Frontier  con- 
ditions long  proVed  an  effective  bar  to  the  development  of  public 
records  of  births,  deaths,  and  marriages.  The  scattered  population 
and  the  individualism  which  has  always  been  impatient  of  official 
interference  in  America — both  hindered  an  accurate  registration. 
The  official  census  was  taken  but  once  in  ten  years,  and  the  data 
thus  secured  were  out  of  date  before  the  results  could  be  published. 
The  need  was  for  an  annual  record.  This  involved  accurate  and 
complete  state  and  local  registration  which  has  not  been  secured  in 
many  of  our  states.  In  1880  records  of  death  based  on  an  effective 
system  were  obtained  from  about  one-sixth  of  the  population  of 
the  country,  but  this  area  had  enlarged  in  1909  to  include  five-ninths 
of  the  population — the  registration  area,  as  it  is  called.  This  area 
,  does  not  include  the  Southern  States  because  their  records  of  deaths 
are  not  sufficiently  complete.  No  longer,  therefore,  do  the  returns 
on  vital  statistics  come  from  the  enumerators  of  the  decennial  census. 
Since  the  establishment  of  a  permanent  Census  Bureau  returns  are 
received  monthly  from  the  registrars  of  state  and  local  mortality  in 
the  registration  area,  and  the  results  are  published  each  year  in  a 
special  report  on  "Mortality  Statistics." 

The  accurate  and  complete  record  of  all  deaths  is  important  be- 
cause the  rate  is  an  index  of  the  condition  of  the  different  commu- 
nities from  year  to  year — the  relative  healthfulness  of  different 
localities  and  occupations;  of  different  age  and  sex  groupings.  It 
shows  up  evil  influences  in  city  life  and  reveals  the  dangers  accom- 
panying civilization. 

(306) 


Sources  of  Information  upon  Public  Health  Movement        63 

The  usual  method  of  securing  a  record  of  deaths  is  to  require 
a  burial  permit,  to  secure  which  a  death  certificate  is  necessary, 
made  out  by  the  physician  who  attended  the  deceased  at  death, 
stating  age,  occupation,  cause  of  death,  etc.  One  great  difficulty  in 
the  way  of  accuracy  has  been  the  lack  of  uniformity  in  this  blank 
form  of  certificate.  Perhaps  no  single  step  taken  by  the  federal 
bureau  has  meant  so  much  for  the  welfare  and  sanitary  protection 
of  the  American  people  as  the  successful  introduction  of  the  "stand- 
ard certificate." 

The  difficulty  of  classification  of  the  causes  of  death  is  a  con- 
stant source  of  error  and  lack  of  uniformity.  Medical  men  have 
made  very  imperfect  returns  of  the  causes  of  death  as  a  result. 
What  do  we  know  about  the  real  incidence  of  tuberculosis  when 
health  officers  allow  deaths  to  be  reported  so  that  they  can  only  be 
classified  as,  "Probably  tuberculosis?"  There  is  much  deliberate 
suppression  of  such  causes  as  alcoholism  and  syphilis.  Sometimes 
there  is  more  than  disease  present,  or  disease  and  accident  together. 
The  adoption  of  the  Bertillon  system  of  classification  of  the  causes 
of  death  over  the  registration  area  and  outside  has  added  greatly 
to  the  uniformity  of  mortality  statistics,  and  renders  the  results  in 
dififerent  places  comparable. 

An  important  aid  in  securing  accurate  statistics  would  come 
from  better  training  on  the  part  of  those  who  are  entrusted  with 
the  registration  of  vital  statistics.  The  recent  rapid  development 
of  the  public  health  movement  has  increased  the  demand  for  this 
training.  In  England,  where  vital  statistics  have  reached  their  high- 
est development,  medical  officers  of  health  are  usually  graduates  of 
great  universities  and,  besides,  of  a  special  course  on  public  health 
in  which  a  diploma  is  given. 

In  the  United  States  the  registration  of  vital  statistics  and  the 
supervision  of  local  health  matters  is  as  likely  to  be  entrusted  to  a 
civilian  as  to  a  physician — at  least  to  one  who  has  devoted  little 
time  or  thought  to  the  larger  problems  of  public  health.  The  work 
of  a  statistician  has  not  yet  been  established  as  a  profession.  Since 
1850  there  have  been  eight  directors  of  our  census,  an  average  length 
of  service  of  four  and  one-half  years.  If  we  compare  the  careers 
of  the  seven  persons  most  conspicuously  identified  with  recent 
census  work  in  England,  France,  Germany,  Prussia,  Italy,  Austria, 
and  Russia,  we  find  the  average  official  life  and  work  in  statistics 

(307) 


64  The  Annals  of  the  American  Academy 

has  been  twenty-six  years,  or  about  six  times  that  in  the  United 
States.  The  accuracy  and  completeness  of  the  statistics  published 
by  the  United  States  Census  Bureau  depend  upon  the  efficiency  of 
local  registration  officials.  An  examination  of  fifty-six  cities  of  the 
United  States  showed  that  in  all  except  eight  the  work  of  registra- 
tion is  entrusted  to  the  health  officers,  as  it  should  be.  In  all  but 
four  the  permit  before  burial  is  in  force.  A  number  of  cities  direct 
that  the  physician  sign  the  certificate  within  a  specified  time,  but 
most  cities  make  no  provision  for  a  certificate  of  death  which  occurs 
without  an  attending  physician. 

One  of  the  greatest  needs  for  the  public  health  movement  is 
more  accurate  records  of  occupational  mortality ;  and,  in  addition, 
data  from  which  the  morbidity  rate  may  be  calculated.  The  annual 
reports  now  publish  mortality  by  age,  sex  and  occupation,  but  the 
United  States  has  almost  nothing  as  to  the  morbidity  rate.  This  one- 
sided information  results  in  wrong  conclusions  from  the  federal  sta- 
tistics, for  instance,  as  to  the  death-rate  among  women  factory 
workers.  It  appears  lower  than  for  any  other  class  of  society — 
the  truth  being  of  course  that  few  women  die  as  factory  workers, 
because  when  death  overtakes  them  most  have  passed  into  the  class 
of  housewives.  Nevertheless,  their  occupation  may  have  been  fatal 
in  undermining  health. 

Besides,  the  mortality  statistics  do  not  give  really  accurate  in- 
formation, because  the  classification  of  the  trades  is  not  sufficiently 
discriminating.  For  example,  the  man  w^orking  at  the  metal  polishing 
wheel  is  classed  with  other  metal  workers.  As  a  result,  the  federal 
figures  do  not  show  the  enormous  death-rate  from  pulmonary  dis- 
eases among  metal  polishers.  For  these  data  we  must  go  to  the 
records  of  the  Metal  Polishers'  Union. 

In  older  European  countries  injury  to  health  in  the  trades  is 
studied  and  controlled  by  the  government.  The  physicians  of  Ger- 
many, France  and  Great  Britain  are  alert  to  the  close  connection 
between  occupation  and  disease. 

The  accuracy  of  figures  on  occupational  mortality  depend  upon : 
(i)  correct  statement  of  occupation  and  age  in  the  enumeration  of 
population  in  the  United  States  census;  (2)  correct  statement  of 
occupation,  by  the  same  classification  as  for  the  United  States  cen- 
sus of  population,  and  correct  age  upon  the  death  certificate;  (3) 
precise  statement  of  the  cause  of  death  upon  the  certificate. 

(308) 


Sources  of  Information  upon  Public  Health  Movement       65 

The  data  are  derived  from  two  different  and  largely  indepen- 
dent sources.  The  returns  of  death,  received  from  the  registration 
states  and  cities,  are  copies  of  the  death  certificate  made  out  by 
physicians  or  relatives.  But  the  occupations  of  the  living  population 
are  stated  by  the  census  enumerators  according  to  instructions. 
The  accuracy  of  statement  may  vary  greatly  in  the  two  sets  of 
returns  even  if  the  classification  of  occupations  be  the  same  in  the 
two  cases,  which  is  likely  not  to  be  the  case.  But  the  only  method 
of  getting  at  the  death-rate  peculiar  to  any  given  occupation  is  to 
compare  the  mortality  in  that  occupation  with  the  number  employed 
for  that  occupation  according  to  the  population  returns.  This  com- 
parison was  attempted  in  the  1900  census,  and  since  that  time  in 
the  annual  reports  on  mortality.  There  is  still  another  difficulty. 
The  population  in  inter-census  years  must  be  estimated  for  each 
occupation.  This  cannot  be  accurately  done  for  more  than  five  years 
after  the  last  general  census.  This  is  an  argument  for  a  population 
census  every  five  years.  Thus,  in  the  "Mortality  Statistics"  for 
1908  it  was  necessary  to  state  simply  the  percentage  which  mortality 
from  a  certain  cause  formed  of  the  mortality  from  all  causes  in  the 
given  occupation.  It  may  be  said  that  the  English  figures  for  oc- 
cupational mortality  are  much  more  complete  and  accurate.  What 
is  needed  in  the  United  States,  both  for  mortality  statistics  and  for 
population  statistics,  is  a  list  containing  all  the  more  important  in- 
dividual occupations,  with  an  exact  statement  of  the  terms  included 
under  each,  so  that  all,  whether  census  enumerator  or  physician  or 
undertaker,  may  comprehend  and  make  a  uniform  and  comparable 
classification  of  occupations. 

Mortality  of  Children. — The  deaths  of  children  should,  if  pos- 
sible, be  recorded  by  single  months  for  the  first  two  years  of  life  and 
for  the  most  important  causes  of  death.  This  is  not  done  in  the 
United  States. 

In  England  and  Wales  infant  deaths  are  recorded  only  during 
the  first  year  by  months,  but  in  Berlin  the  record  is  by  months  for 
the  first  two  years.  These  facts  are  of  great  importance  in  the 
problem  of  infant  mortality.  Besides,  there  should  be  a  distinction 
made  between  deaths  of  children  breast-fed  and  bottle-fed,  since 
these  data  throw  light  on  the  solution  of  the  problem  of  infant 
mortality. 

On  page  50  of  the  annual  report  of  the  medical  officer  of  health 

(309) 


66  The  Annals  of  the  American  Academy 

of  Blackburn,  England,  the  particulars  of  the  nursing  and  feeding 
of  2,705  children  under  7  months  old  are  given. 

Registration  of  Births. — In  the  '"Supplementary  Analysis  of 
the  Twelfth  Census,"  page  2^y,  we  find  the  following  statement: 
"The  twelfth  census  contains  no  statistics  of  births  or  marriages. 
It  has  been  found  impracticable  to  gather  information  through 
census  enumerators  regarding  either  the  births  or  the  marriages 
that  occurred  during  the  census  year  with  enough  completeness 
to  make  the  resulting  figures  worth  the  cost.  The  records  of 
state  or  municipal  registration  offices  upon  births  and  marriages 
— the  only  alternative  sources  of  information — are  often  lacking, 
and  where  they  exist  are  incomplete  in  so  many  cases  that  no 
satisfactory  statistics  of  births  or  marriages  for  the  United  States 
can  be  derived  from  them."  In  his  contribution  to  the  "Report 
of  Vital  and  Social  Statistics  of  the  Eleventh  Census,"  published 
in  1896,  Dr.  Billings  stated:  "We  have  no  fully  complete  and 
accurate  registration  of  births  in  any  part  of  the  United  States." 
W.  A.  King,  chief  statistician  for  vital  statistics  in  the  twelfth 
census,  began  his  discussion  of  births  by  admitting  that  "the  data 
relating  to  births  are  the  most  incomplete  and  unsatisfactory  of  any 
treated  in  this  report.  Were  it  not  considered  desirable  to  give  such 
results  as  bear  upon  the  question  for  the  information  of  students 
of  statistics,  the  subject  might  be  dismissed  with  the  statement  that 
they  are  entirely  inadequate  to  determine,  directly,  the  general  birth 
rate  of  the  country,  or,  what  is  of  equal  practical  importance,  the 
relative  birth  rate  of  different  classes  of  the  population." 

The  registration  of  births  is  extremely  important  for  the  knowl- 
edge of  infant  mortality,  for  the  protection  of  infant  life,  and  for 
securing  the  legal  rights  of  children.  Yet,  not  a  single  State  in  the 
Union,  nor  a  single  city  of  any  considerable  size,  makes  positive 
claim  that  it  registers  as  many  as  nine  births  out  of  every  ten  that 
occur.  Even  the  city  of  Washington,  whose  law  for  this  purpose 
is  a  direct  enactment  of  Congress,  does  not  exceed  this  limit  of 
efficiency.  "The  registration  area  for  births  consists  of  a  few 
interrogation  points."  It  was  not  until  1891  that  the  annual  num- 
ber of  recorded  births  in  New  York  City  exceeded  the  number  of 
deaths. 

The  total  number  of  births  must  be  known  before  a  computa- 
tion of  infant  mortality  can  be  made  which  will  be  comparable  with 

(310) 


Sources  of  Information  upon  Public  Health  Movement        6y 

the  rates  given  in  the  vital  statistics  of  all  civilized  nations  except 
the  United  States.  The  infant  death  rate  depends  upon  the  com- 
parison of  deaths  under  i  year  of  age  with  the  total  births.  In  this 
respect  the  infant  death  rate  differs  from  that  of  other  age  groups, 
which  is  a  comparison  of  the  deaths  at  a  given  age  with  the  popula- 
tion living  at  that  age. 

In  the  absence  of  accurate  registration  of  births,  the  United 
States  census  has  been  at  a  loss  to  compute  birth  rates.  The  only 
way  to  obtain  an  approximate  estimate  for  the  whole  country,  or 
for  a  State,  is  to  take  the  number  of  children  under  i  year  of  age, 
found  living  at  the  date  of  the  census,  and  add  to  this  the  number 
of  children  who  died  during  the  census  year  and  who  were  born 
during  that  same  year.  In  absence  of  accurate  data  for  computation 
of  the  birth  rate,  the  census  officials  resort  to  the  method  of  com- 
paring the  number  of  children  in  the  population  to  the  number  of 
women  of  child-bearing  age,  from  decade  to  decade,  in  order  to 
secure  evidence  as  to  the  decline  of  the  birth  rate,  as  described  in 
Bulletin  No.  22,  of  the  census.  Thus,  the  ratio  of  the  living  children 
under  5  years  of  age  to  each  i.gcxd  living  women  of  child-bearing 
age  is  used  as  the  best  available  substitute  for  the  birth  rate  in  the 
United  States  since  1850.  But  this  ratio  is  not  comparable  with 
other  countries  which  have  accurate  registration. 

-?.     State  and  Local  Reports  of  Vital  Statistics 

The  collection  of  vital  statistics  received  its  first  impetus  in 
towns  where  registration  of  deaths  was  desired  for  sanitary  ends. 
Dr.  Edward  Jarvis  states  that  New  York  City  began  to  publish 
mortality  statistics  in  1804;  Boston  in  1813;  Philadelphia  in  1825, 
and  Baltimore  in  1836.  The  States  in  which  these  cities  are  located 
did  not  legislate  until  later.  The  most  striking  characteristic  of 
these  state  and  municipal  reports  is  their  lack  of  uniformity.  The 
data  of  one  State  or  city  are,  therefore,  not  comparable  with  those 
of  another  State  or  city.  In  fact,  these  local  reports  are  not  suffi- 
ciently uniform  to  admit  of  the  comparison  of  the  data  in  suc- 
cessive reports.  As  pointed  out  earlier  in  this  paper,  the  officials 
to  whom  the  work  of  registration  has  been  intrusted  in  the  United 
States  have  not  had  sufficient  training  either  in  statistical  method 
or  in  the  importance  of  the  various  public  health  problems.  The 
adoption  of  the  "standard  certificate"  of  death,  and  the  wide  adop- 

(311) 


68  The  Annals  of  the  American  Academy 

tion  of  the  Bertillon  system  of  classification  of  the  causes  of  death, 
have  brought  a  greater  degree  of  uniformity  into  mortality  records. 
Nevertheless,  the  accuracy  of  registration  still  depends  in  large 
measure  upon  the  efficiency  of  the  local  official,  who  may  correct 
errors  on  the  certificate  of  death  if  he  is  sufficiently  alert  to  its 
importance. 

The  American  medical  press  is  not  critical  enough  of  the  con- 
tents, nature  and  objects  of  local  health  reports.  As  yet,  there  is 
no  clear  recognition  of  the  real  local  value  of  such  reports.  As  a 
result  of  a  more  careful  and  scientific  study  of  vital  statistics,  it  may 
be  possible  to  set  forth  clearly  that  the  great  waste  of  life  can  be 
diminished  by  measures  to  prevent  accidents  or  the  unnecessary 
prevalence  of  disease. 

Local  health  reports  fail  to  make  a  careful  study  of  the  local 
mortality  as  affected  by  race,  nativity  and  occupation.  If  the  ages  at 
death  are  given  at  all,  they  are  generally  given  by  arbitrary  divisional 
periods  of  life.  Rarely  is  any  information  published  locally  as  to 
mortality  by  occupation,  and  yet  this  is  essential  to  a  knowledge  of 
the  relative  influence  upon  the  health  of  workers  of  various 
occupatipns. 

Mortality  from  special  causes,  by  streets  or  by  wards,  is  often 
useful  information  in  locating  the  causes  of  disease.  In  Liverpool, 
England,  for  example,  to  emphasize  the  prevalence  of  diarrhoea  in 
1905,  a  table  was  prepared  showing  the  mortality  by  streets  on 
which  three  or  more  deaths  from  this  disease  occurred.  The  Boston 
Registry  Department  gives  a  full  account  of  the  elements  of  the 
population  and  the  mortality  of  every  ward  in  the  city.  Most 
reports  of  boards  of  health  give  an  elaborate  analysis  of  mortality 
by  months,  instead  of  giving  the  necessary  data  by  ages  at  death. 
For  many  important  purposes,  age  and  sex  distribution  are  needed, 
while  the  distribution  by  months  is  of  only  limited  significance. 

Wherever  the  colored  population  exceeds  10  per  cent,  of  the 
total,  the  mortality  should  be  separated  by  color.  The  mortality  rates 
are  so  different  in  the  two  elements  of  population,  that  frequently 
comparison  of  two  places  with  different  proportions  of  white  and 
colored  is  impossible  unless  the  mortality  is  stated  separately  for 
the  two  races.  The  same  would  be  true  in  comparing  different 
wards  of  a  city. 

The  health  and  mortality  of  school  children  of  6  to  14  years 

(312) 


Sources  of  Information  upon  Public  Health  Movement       69 

of  age  is  a  matter  of  great  concern  at  present.  The  school  officials 
might  be  requested  to  report,  week  by  week,  the  deaths  among  their 
pupils.  A  table  could  then  be  constructed  at  the  end  of  the  year, 
showing  the  average  number  of  pupils  in  different  schools  according 
to  grades,  with  the  mortality  in  each,  together  with  a  statement  of 
ages  at  death  and  the  principal  causes  of  mortality.  These  data 
would  throw  light  upon  the  problem  of  school  hygiene. 

Mortality  from  trade  diseases  and  accidents  is  of  the  greatest 
concern  to  those  interested  in  the  preservation  of  national  vitality 
and  efficiency.  Present  local  methods  of  presenting  occupation- 
mortality  statistics,  where  they  are  given  at  all,  are  usually  very 
crude,  and  the  tables  are  of  little  value.  The  best  work  in  this  field 
is  found  in  England,  in  the  reports  of  Sheffield  and  Blackburn — the 
former  for  the  cutlery  trade,  the  latter  for  textiles.  The  Black- 
burn report  might  serve  as  a  model  for  such  cities  of  the  United 
States  as  Fall  River  and  Lawrence.  Such  tables  in  the  United 
States  would  afford  an  accurate  insight  into  the  extent  of  indus- 
trial disease.  For  these  data  in  this  country  we  must  depend  upon 
insurance  companies,  labor  unions  or  private  investigations.  The 
Rhode  Island  reports  state  only  the  average  age  at  death  among  men 
dying  in  different  trades,  instead  of  giving  age  distribution  by 
periods  of  life  and  the  more  important  causes.  Where  the  reports 
are  limited  to  specific  trades  (t.  e.,  textiles),  the  causes  of  death 
need  not  be  extended  beyond  tubercular  and  respiratory  diseases  and 
accidents.  Dangerous  trades  where  accidents  are  likely  to  occur 
(t.  e.,  iron  and  steel)  should  be  reported  in  detail — every  fatal  acci- 
dent, with  age,  specific  occupation  and  cause  of  death.  The  agita- 
tion for  workmen's  insurance  or  compensation  should  rest  upon 
accurate  data,  which  at  present,  in  the  United  States,  do  not  exist. 

Besides  what  has  been  already  said  as  to  the  inadequate  pro- 
visions for  the  registration  of  births,  the  local  importance  of  the 
earliest  possible  registration  of  births  needs  emphasis,  in  the  interest 
of  public  health  and  the  movement  against  high  infant  mortality. 
Early  registration  facilitates  the  work  of  the  health  visitor  and 
sanitary  inspector.  The  New  York  law  requires  report  within  ten 
days,  and  imposes  a  $100  fine,  in  addition  to  making  the  failure  to 
report  a  misdemeanor.  Some  States  offer  a  fee  to  the  physician  for 
registration  of  births. 


(313) 


70  The  Annals  of  the  American  Academy 

5.    Reports  of  Hospitals  and  Institutions  for  Defectives, 
Dependents  and  Delinquents 

For  hospitals,  most  of  the  reports  are  decidedly  defective  and 
more  or  less  misleading.  Cases  are  duplicated,  and  there  is  lack 
of  uniformity  in  description.  Improved  methods  are  needed,  and 
it  seems  advisable  for  local  health  officers  to  insist  upon  accurate 
and  specific  returns  from  such  institutions,  in  order  that  the  real 
mortality  rate  may  be  known.  The  mortality  record  should  show, 
in  a  special  table,  the  deaths  of  inmates  by  age  and  cause  of  death, 
with  a  statement  of  the  average  number  of  inmates.  These  tables 
would  correct  wrong  conclusions  as  to  the  healthfulness  of  particular 
localities.  Furthermore,  the  deaths  in  institutions  should  be  redis- 
tributed, according  to  the  place  of  residence  of  the  deceased,  to 
prevent  errors,  which  are  especially  serious  in  the  case  of  hospitals 
for  the  treatment  of  special  diseases,  which  attract  large  numbers 
from  outside  the  locality.  Not  even  New  York  City  makes  a 
proper  redistribution.  London  does  make  this  correction.  The 
tables  of  institutions  do  not,  as  a  rule,  conform  to  the  method  of 
showing  mortality  at  different  ages  and  for  specified  causes. 

Defectives,  Dependents  and  Delinquents. — The  president  of 
the  National  Conference  of  Charities  and  Correction,  in  his  in- 
augural address  in  1891,  discussed  state  and  national  registration 
of  defectives,  dependents  and  delinquents.  He  pointed  out  the 
fact  that  before  the  tables  of  the  decennial  census  were  issued 
they  ceased  to  have  scientific  value.  Reports  in  the  States,  he 
characterized  as  lacking  in  completeness,  uniformity  and  scientific 
methods.  He  proposed  to  introduce  the  efficient  methods  of  the 
charity-organization  societies,  as  illustrated  from  their  experience  in 
New  York,  Boston,  Buffalo  and  Indianapolis,  into  state  boards  of 
charity,  in  order  to  secure  accurate  registration  and  classification. 
The  conference  has  a  committee  on  statistics  which  makes  a  report 
at  each  session  and  seeks  to  promote  uniformity  and  completeness 
in  records. 

There  is  no  lack  of  statistical  output,  but  the  product  is  un- 
finished and  largely  indigestible.  Busy  men  and  women  have  no 
time  to  disentangle  real  information  from  unrelated  masses  of  data. 
We  have  not  even  a  trustworthy  quantitative  measure  of  the  feeble- 
minded in  the  United  States.     The  numerical  strength  of  the  insane 

(314) 


Sources  of  Information  upon  Public  Health  Movement        71 

outside  of  institutions  is  unknown.  Current  institutional  statistics 
are  not  of  a  sort  to  greatly  promote  our  knowledge  of  insanity  as  a 
social  phenomenon.  Not  long  since,  a  foreign  official  asked  for  the 
statistics  of  the  number  of  persons  in  the  United  States  supported 
through  public  outdoor  and  indoor  relief.  He  was  astonished  by 
the  reply  that  the  facts  were  beyond  any  one's  knowledge.  He 
wished,  further,  to  learn  the  number  of  destitute  children  cared  for 
by  public  and  private  agencies.  Only  the  roughest  estimate  could 
be  given. 

There  is  a  woeful  lack  of  competent  statistics  of  poverty  and 
pauperism.  We  need  more  data  and  better  analysis.  Theories  of 
social  amelioration  should  be  based  upon  a  thorough  study  of  the 
facts,  and  the  results  should  be  tested  by  careful  records.  The 
reports  of  the  census  office  in  1906  on  paupers  in  almshouses  and 
benevolent  institutions,  prepared  by  John  Koren,  expert  and  special 
agent,  mark  the  beginning  of  a  new  era  of  intelligent  inquiry — the 
first  step  for  a  proper  understanding  of  the  existing  state  of  the 
social  ill  health.  For  the  first  time  we  possess  a  definite  basis  of  fact 
as  to  the  extent  of  pauperism  in  the  United  States.  In  foreign 
countries  more  has  been  done  on  this  problem,  because  it  is  more 
pressing.  An  interesting  attempt  at  international  comparison  will  be 
found  in  the  second  series  of  reports  on  British  and  foreign  trade 
and  industry.  This  report  includes  much  statistical  material  on 
poverty  and  pauperism  in  the  most  civilized  countries,  including  the 
United  States.  Want  of  uniformity  in  American  statistics,  how- 
ever, made  it  impossible  for  the  report  to  utilize  other  than  the 
state  returns  of  New  York,  Massachusets  and  Minnesota,  which  are 
scarcely  representative  of  the  country. 

The  German  Union  investigated  seventy-seven  German  cities, 
and  published  the  results  in  1886-1888.  A  committee  of  statisticians 
formulated  a  plan  and  secured  the  co-operation  of  the  relief  officers 
of  the  various  localities.  In  each  city  cards  on  a  uniform  scheme 
were  furnished.  The  work  was  done  by  government  officials, 
directed  by  a  committee  of  the  Union,  and  paid  for  by  the  cities.  A 
rate  of  dependency  was  thus  calculated  for  seventy-seven  cities,  with 
a  population  of  over  four  millions. 

The  centralized  system  of  the  English  Local  Government  Board 
furnishes  each  year  very  complete  statistics  of  outdoor  and  indoor 
relief.      In  the  United  States  the  charity-organization  reports  are 

(315) 


72  The  Annals  of  the  American  Academy 

valuable,  but  no  statistics  exist  that  compare  with  those  of  Eng- 
land and  Germany.  The  reports  of  state  boards  of  charity  are, 
as  a  rule,  so  imperfect  as  to  be  exasperating  to  the  investigator. 
The  committee  of  the  National  Conference  collected  data  for  a 
year,  and  then  had  to  report  that  "your  committee  does  not  pretend 
to  oflfer  complete  statistics  for  even  one  community."  And  yet  it 
is  not  too  much  to  say  that  correct  and  uniform  records  lie  at  the 
foundation  of  modern  charity  work. 

In  correction,  a  German  investigator  declared  as  to  Amer- 
ican conditions :  "They  are  lacking  complete  statistics  in  each  case." 
We  leave  practically  unworked  the  primary  sources  of  information ; 
i.  e.,  the  records  of  police  courts,  grand  juries,  etc.  A  statistical 
test  has  never  been  applied  to  our  system  of  penology  as  a  whole. 
Our  bookkeeping  is  so  imperfect  that  we  do  not  know,  even  approxi- 
mately, the  extent  of  the  local  juvenile  delinquency  problem. 

I  shall  enumerate  other  sources  of  information  on  matters 
related  to  the  public  health  movement,  without  detailed  criticism : 

(i)  Reports  of  local  charity-organization  societies,  medical 
societies,  tuberculosis  associations  and  labor  unions. 

(2)  Records  of  insurance  companies. 

(3)  Commissions  on  the  problem  of  industrial  accidents  and 
their  compensation. 

(4)  Annual  school  reports. 

(5)  Special  reports  on  the  following  topics: 

a.  "Immigration,"  by  the  commission. 

b.  "Women  in  Industry,"  by  the  Bureau  of  Labor. 

c.  "Workmen's  Budgets,"  by  Robert  Chapin  and  Mrs.  L. 

B.  More. 

d.  "Industrial  Accidents  and  Dangerous  Trades,"  by  the 

Bureau  of  Labor. 

e.  "Wages,"  Twelfth  Census. 

/.  "Child  Labor,"  by  state  and  local  agencies. 

g.  Report  on  "National  Vitality,"  by  Irving  Fisher. 

h.  Backward  school  children ;  physical  defects. 

II.    Caution  in  the  Use  of  Statistical  Data  Needed 

We  live  amid  a  wilderness  of  recorded  data.  Prophets  seize 
eagerly  upon  the  chaotic  mass  embodied  in  reports  called  statistics, 
and  appropriate  such  facts  as  meet  their  needs — then  they  proclaim 

(316) 


Sources  of  Information  upon  Public  Health  Movement        73 

this  version  of  the  facts  as  the  truth.  Some  one  declares  that 
500,000  persons  have  received  reUef  in  New  York  City  during  the 
last  year ;  another  exclaims,  "I  hear  the  wail  of  2,000,000  children 
who  are  in  want" ;  still  another  is  sure  that  his  statistics  prove  that 
the  jails,  almshouses,  hospitals  for  the  insane,  and  most  other  public, 
institutions  are  chiefly  populated  by  immigrants. 

When  two  quantities  are  compared  we  must  consider  whether 
they  are  comparable.  If  we  compare  the  general  death  rates  of  two 
cities  in  which  there  are  widely  different  proportions  of  colored  and 
white  population  error  will  be  sure  to  arise  because  of  the  higher 
death  rate  among  colored,  if  we  conclude  as  to  the  relative  health- 
fulness  of  the  two  cities  from  the  figures  given.  It  is  never  safe  to 
take  published  statistics  at  their  face  value  without  knowing  their 
meaning  and  limitations.  The  actual  use  and  appreciation  of  sta- 
tistics is  ultimately  a  matter  of  intelligence,  special  knowledge,  and 
common   sense.     The    following  are   illustrations   of   error: 

(1)  The  Census  of  1890  presented  very  wrong  inferences  from 
some  of  its  statistics.  It  was  claimed,  for  example,  that  for  each 
million  of  the  foreign-bom  there  were  1.768  prisoners,  while  for  each 
million  of  the  native-born  there  were  only  898.  These  facts,  so  it 
was  claimed,  showed  a  tendency  to  criminality  among  the  foreign- 
born  twice  as  great  as  among  the  native-born.  But  this  inference 
overlooked  a  most  important  fact — i.  e.,  that  criminals  are  recruited 
mainly  from  adults,  and  that  the  proportion  of  foreign-born  adults 
to  the  total  foreign-born  population  is  much  greater  than  that  of  the 
native-born  adults  to  the  native  population.  The  latter  includes  many 
more  children.  If  we  compare  the  number  of  male  prisoners  with 
the  number  of  males  of  voting  age,  a  very  different  result  appears. 
The  number  of  male  prisoners  per  1,000,000  of  voting  age  in  1890 
was  as  follows: 

Native  white  of  native  parents 3>395 

Native  white  of  foreign  parents 5,886 

Foreign  whites  3,270 

In  this  analysis,  age  for  age,  the  foreign-born  show  a  lower 
rate  than  the  native-born.  Besides,  the  table  shows  criminality 
among  the  native-born  of  foreign  parents  twice  as  high  as  either 
of  the  other  groups.    This  requires  an  explanation  and  a  remedy. 

(2)  The  report  of  the  Secretary  of  War  in  1899  discussed  the 

(317) 


74  The  Annals  of  the  American  Academy 

rate  of  death  from  diseases  in  the  PhiHppines  among  the  soldiers 
(17.2  per  1,000).  He  compared  this  rate  with  rates  among  the 
general  population  in  Washington  and  Boston,  and  it  appeared  not 
excessive  when  so  compared.  But  such  comparison  of  the  death 
rate  of  soldiers,  mostly  18  to  30  years  of  age,  could  not  be  made 
with  a  city  population  of  all  ages,  including  infants,  where  the 
death  rate  is  so  high.  Besides,  soldiers  represent  a  selected  class. 
If  he  had  compared  the  rate  for  soldiers  with  the  rate  among  the 
general  population,  15  to  45  years  of  age,  he  would  have  observed 
it  to  be  about  10.9  per  1,000,  which  would  still  not  have  allowed 
for  the  selected  class.  If  he  had  compared  the  rate  in  the  Philip- 
pines with  the  rate  among  United  States  soldiers  before  the  Spanish 
war  he  would  have  found  it  to  be  four  times  as  great. 

(3)  If  we  consult  the  table  on  mortality  among  males  and 
females  in  1908  for  the  registration  area.  Bulletin  104,  the  following 
appears :  Percentage  of  gainfully  employed  to  the  zvhole  number  of 
deaths — 

Age 
Grouping.  Males.  Females. 

All    ages 52.3  8.3 

10-14    years    4.0  1.7 

15-19      "         58.3  25.7 

20-24      " 82.7  28.0 

25-34      "        86.5  19.2 

35-44      "        85.7  16.2 

If  the  conclusion  followed  from  these  figures  that  mortality  of 
women  in  industry  is  slight,  it  would  overlook  the  important  fact 
that  many  women  have  left  industry  and  became  housewives  when 
diseases  prove  fatal.  For  exact  conclusions  we  need  facts — i.  e., 
the  morbidity  rate  among  women  in  industry. 

(4)  Suppose  we  have  two  cities  of  1,000  each.  We  assume  the 
same  death  rate  for  each  at  the  same  ages — /.  e.,  under  10  years,  a 
death  rate  of  100  per  1,000;  over  10  years,  a  rate  of  10  per  1,000. 
The  distribution  in  town  A  by  ages  is  100  under  10  years,  and  900 
over  10  years  ;  in  town  B,  150  under  10  years,  and  850  over  10  years 
Therefore,  the  crude  rate  for  A  will  be  19,  and  for  B  23.5  per  1,000. 
This  apparent  difference  is  caused  by  the  presence  of  a  larger  pro- 
portion of  children  in  B  among  which  the  rate  is  always  higher — the 
difference  is  not  due  to  difference  in  health  fulness  of  the  two  towns. 

(3t8) 


Sources  of  Information  upon  Public  Health  Movement        75 

It  is,  evidently,  impossible  to  compare  the  health  fulness  of  two 
localities  until  differences  in  the  death  rate  due  to  different  age- 
grouping  have  been  excluded.  If  comparison  is  made  on  the  basis 
of  the  crude  uncorrected  rate  error  may  result.  Statistical  method 
has  a  way  of  correcting  death  rates  for  difference  in  sex  and  age- 
grouping  which  will  render  the  results  comparable  in  determining 
relative  health  fulness. 

(5)  The  chief  function  of  statistics  is  to  show  correlation  of 
data  and  thus  arrive  at  the  relations  of  cause  and  effect.  But  often 
a  single  correlation  leaves  out  of  consideration  other  important  corre- 
lations. An  instance  of  this  error  is  found  in  the  annual  report  of 
a  western  college  in  which  comparison  of  the  average  standing  and 
failures  among  non-smokers,  moderate  smokers  and  excessive 
smokers  is  made: 

Non-Smokers.         Moderate.  Excessive. 

Number  of  Students  in  35  18 

Average  for  year   85.2%  7ii7o  597% 

Percentage  of  failures    3-2%  14.1%  24.1% 

From  these  data  it  was  concluded  that  smoking  was  the  cause 
of  the  failure  of  a  very  large  percentage  of  those  who  smoked.  The 
correlation  is  clear  but  the  explanation  is  not  adequate.  The  men 
who  smoked  in  that  college  were  those  who  for  other  reasons  would 
have  valued  other  things  more  than  marks.  They  went  in  society, 
they  were  prominent  in  athletics,  or  they  were  the  fellows  who  did 
not  come  to  college  to  study.  Smoking  was  one  of  the  things  they 
did  to  pass  the  time. 

If  space  permitted,  this  paper  would  be  made  much  more  com- 
plete by  a  presentation  of  some  concrete  data  on  such  problems  as 
tuberculosis,  medical  inspection  in  the  schools,  infant  mortality  and 
trade  diseases  and  industrial  accidents,  which  would  make  clear  just 
how  statistics  may  throw  light  upon  the  problems  with  which  the  pub- 
lic health  movement  is  most  concerned.  Prevention  means  getting  at 
the  causes,  and  statistics  show  where  to  look  for  these  causes.  The 
removal  of  the  causes  then  becomes  a  matter  of  public  policy,  the 
results  of  which  are  to  be  tested  by  a  further  collection  of  statistical 
data.  Thus  the  beginning  and  the  end  of  the  movement  toward 
social  amelioration  appeals  to  the  science  of  statistics  for  its  aid 
and  g^tidance. 

(319) 


76  The  Annals  of  the  American  Academy 

In  conclusion,  the  great  needs  seem  to  be  for  a  more  complete 
and  accurate  registration  of  local  vital  statistics,  greater  uniformity 
in  classifications,  more  training  on  the  part  of  those  who  have  charge 
of  the  records,  and  a  higher  appreciation  of  the  usefulness  of  sta- 
tistical data.  The  National  Government  may  perform  at  least  two 
functions  in  the  great  public  health  movement — i.  e.,  ( i )  investiga- 
tion and  (2)  dissemination  of  information.  To  do  this  there  is  need 
for  a  Bureau  of  Public  Health  which  shall  become  the  central  inves- 
tigating agency  and  depository  for  the  results  gathered  from  the 
whole  country.  This  bureau  will  seek  to  promote  uniformity  of 
classification  which  will  make  the  results  comparable,  and  will  in- 
form public  opinion  by  well-ordered  and  authentic  facts. 


(320) 


WORK  OF  THE  COMMITTEE  OF  ONE  HUNDRED  ON 
NATIONAL  HEALTH 


By  Wm,  Jay  Schieffelin,  Ph.D., 
Chairman  of  the  Executive  Committee  of  the  Committee  of  One  Hundred 

on  National  Health. 


Professor  J.  P.  Norton,  of  Yale,  in  a  paper  read  in  June,  1906, 
before  the  Economic  Section  of  the  American  Association  for  the 
Advancement  of  Science,  showed  that  the  country  is  suffering  great 
economic  losses  from  preventable  sickness  and  premature  deaths. 
He  advocated  the  creation  of  a  National  Department  of  Health, 
which  should  spread  throughout  the  country  a  knowledge  of 
effective  ways  of  stamping  out  disease,  as  the  Department  of  Agri- 
culture has  done  in  the  case  of  cattle.  As  a  result  of  this  paper, 
a  committee  of  one  hundred  on  national  health  was  appointed  to 
study  its  subject,  and  to  put  into  eflFect  the  best  methods  for  securing 
its  object.  The  committee  elected  Professor  Irving  Fisher,  of  Yale, 
president.  It  was  later  voted  by  the  association  that  the  com- 
mittee,^ instead  of  merely  representing  its  economic  section,  should 

>The  present  make-up  of  the  Committee  is  as  follows : 

President — Professor   Irving   Fisher. 

Vice-Presidents — Ex-President  James  B.  Angell,  Ann  Arbor :  Kx-President 
Charles  W.  Eliot,  Cambridge ;  Uev.  Lyman  Abbott,  New  York ;  Miss  Jane  Addams, 
Chicago ;  Mr.  Felix  Adler,  New  York ;  Hon.  Joseph  H.  Choate,  New  York ;  .Arch- 
bishop Ireland,  St.  Paul ;  Hon.  Ben  B.  Lindsey,  Denver ;  Mr.  John  Mitchell,  New 
York;  Dr.  William  H.  Welch,  Baltimore. 

Executive  Officers — Chairman  Executive  Committee,  Wm.  Jay  Schieffelin, 
Ph.D. ;  Secretary,  Edward  T.  Devine.  Ph.D.,  LL.D. ;  Treasurer,  Title  Guarantee  and 
Trust  Company,  176  Broadway,   New  York  City. 

Committee  of  One  Hundred — Dr.  A.  C.  Abbott,  Philadelphia,  Pa. ;  Rev.  Lymaa 
Abbott,  New  York  City ;  Samuel  Hopkins  Adams,  New  York  City ;  Miss  Jane 
Addams,  Chicago,  111. ;  Felix  Adler,  New  York  City ;  William  H.  Allen,  Ph.D.,  New 
York  City ;  Ex-President  James  B.  Angell,  Ann  Arbor.  Mich. ;  Dr.  Hermann  Biggs, 
New  York  City ;  Dr.  Frank  Billings,  Chicago,  111. ;  Miss  Mabel  T.  Boardman,  Wash- 
ington,  D.  C. ;  Edward  Bok,  Philadelphia,  Pa. ;  Mrs.  Ballington  Booth,  Montclalr, 
N.  J. ;  C.  Loring  Brace,  New  York  City ;  Bishop  C.  H.  Brent,  Manila,  P.  I. ;  Dr. 
Joseph  D.  Bryant,  New  York  City ;  Luther  Burbank,  Santa  Rosa,  Cal. ;  Andrew 
Carnegie,  New  York  City ;  Prof.  James  McKeen  Cattoll,  New  York  City ;  Prof.  R.  H. 
Chittenden,  New  Haven,  Conn. ;  Hon.  Joseph  H.  Choate,  New  York  City ;  Dr. 
Thomas  D.  Coleman,  Augusta.  Ga. ;  Prof.  John  R.  Commons,  Madison,  Wis. ;  Dr. 
Thomas  Darlington,  New  York  City :  Edward  T.  Devine,  Ph.D.,  LL.D.,  New  York 
City ;  Mrs.  Melvil  Dewey,  Lake  Placid,  N.  Y. ;  Dr.  A.  H.  Doty,  New  York  City ; 
Thomas   A.    Edison.    Orange,    N.    J. ;    Ex-President,    Charles   W.    Elliot,    Cambridge, 

(321) 


78  TJic  Annals  of  the  American  Academy 

represent  the  whole  association,  and  that  the  scope  of  its  work 
should  not  be  confined  to  advocating  a  National  Department  of 
Health,  but  should  include  the  prosecution  of  all  suitable  work  for 
securing  improved  national  health. 

The  committee  adopted  the  policy  of  not  attempting  much  direct 
work  for  improving  health  conditions,  but  rather  of  inducing  other 
agencies,  already  existing  and  equipped,  to  do  the  work.  It  has 
aimed  especially  to  enlist  the  services  of  three  great  agencies,  the 
press,  the  insurance  companies,  and  the  government. 

At  the  outset  the  committee  was  confronted  with  the  fact  that 
very  little  information  exists  concerning  the  health  of  the  nation 
as  a  whole.  Actual  facts  as  to  deaths  are  available  in  only  half 
of  the  population.  Of  the  remainder  we  do  not  even  know  how 
many  deaths  occur.  Before  the  nation  can  intelligently  do  its  part 
of  the  work  of  disease  prevention,  the  national  aspect  of  diseases, 

Mass. ;  Rev.  W.  G.  Eliot,  Jr.,  Portland,  Ore. ;  Dr.  Livingston  Farrand,  New  York 
City ;  Hon.  Charles  J.  Faullcner,  Washinston,  D.  C. ;  Dr.  Henry  B.  Favlll,  Chicago. 
111. ;  Dr.  George  J.  Fisher,  New  York  City ;  Prof.  Irving  Fisher,  New  Haven,  Conn. ; 
Horace  Fletcher,  New  York  City  ;  Austen  G.  Fox,  New  York  City  ;  Lee  K.  Frankel. 
Ph.D.,  New  York  City  ;  Dr.  John  S.  Fulton,  Washington,  D.  C.  ;  President  II.  A. 
Garfield,  Williamstown,  Mass. ;  W^Illiam  R.  George,  Freevllle,  N.  Y.  ;  Prof.  Franklin 
II.  Giddings,  New  York  City ;  E.  R.  L.  Gould,  New  York  City ;  Rev.  Percy  S.  Grant. 
New  York  City ;  Dr.  Luther  H.  Gulick,  New  York  City ;  President  A.  T.  Iladley, 
New  Haven,  Conn. ;  Norman  Hapgood,  New  York  City ;  Miss  Hazard,  Peace  Dale, 
R.  I.  ;  Prof.  C.  R.  Henderson,  Chicago,  111. ;  Mrs.  John  B.  Henderson,  Washington, 
D.  C. ;  Calvin  W.  Hendrick,  Baltimore,  Md.  ;  Byron  W.  Holt,  New  York  City ; 
Prof.  L.  Emmett  Holt,  New  York  City ;  Dr.  J.  N.  Ilurty,  Indianapolis,  Ind.  ;  Rt 
Rev.  John  Ireland,  St.  Paul,  Minn.  ;  Prof.  M.  E.  Jaffa,  Berkeley,  Cal.  ;  Prof. 
Jeremiah  W.  Jenks,  Ithaca,  N.  Y. ;  Dr.  P.  M.  Jones,  San  Francisco,  Cal. ;  President 
David  Starr  Jordan,  Stanford  University,  California ;  Prof.  Edwin  O.  Jordan, 
Chicago,  111.  ;  Arthur  P.  Kellogg,  New  York  City  ;  Dr.  J.  II.  Kellogg,  Battle  Creek, 
Mich.  ;  Dr.  S.  A.  Knopf,  New  York  City  ;  Dr.  George  M.  Kober,  Washington,  D.  C. ; 
Dr.  George  F.  Kunz,  New  York  City ;  Prof.  James  Law,  Ithaca,  N.  Y. ;  Samuel 
McCune  Lindsay,  New  York  City ;  Hon.  Ben  B.  Lindsey,  Denver,  Col.  ;  Dr. 
Jaques  Loeb,  Berkeley,  Cal..;  Hon.  John  D.  Long,  Boston,  Mass. ;  S.  S.  McClure, 
New  York  City ;  Dr.  J.  N.  McCormack,  Bowling  Green,  Ky.  ;  Iliram  J.  Messenger. 
Hartford,  Conn. ;  John  Mitchell,  New  York  City ;  Hugh  Moore,  New  York  City ; 
Dr.  Prince  A.  Morrow,  New  York  City  :  Dr.  Richard  C.  Newton,  Montclair,  N.  J  ; 
Prof.  M.  V.  O'Shea,  Madison.  Wis. ;  Walter  II.  Page,  Garden  City,  L.  I. ;  Henry 
Phlpps,  New  York  City ;  Dr.  C.  O.  Probst,  Columbus,  Ohio ;  Dr.  Charles  A.  L.  Reed, 
Cincinnati,  Ohio ;  Mrs.  Ellen  II.  Richards,  Boston,  Mass. ;  Dr.  R.  A.  Sargent, 
Cambridge,  Mass. ;  William  Jay  Schleffelin,  Ph.D.,  New  York  City ;  Prof.  Henry 
R.  Seager,  New  York  City;  Hon.  George  Shiras,  III,  Washington,  D.  C. ;  Dr. 
George  H.  Simmons,  Chicago,  111. ;  President  William  F.  Slocum,  Colorado  Springs, 
Col. ;  Dr.  Charles  D.  Smith,  Portland,  Me. ;  Dr.  Z.  T.  Sowers,  Washington,  D.  C. ; 
James  Sprunt,  Wilmington,  N.  C. ;  Melville  E.  Stone,  New  York  City :  Nathan 
Straus,  New  York  City :  .T.  E.  Sullivan,  New  York  City ; ;  William  H.  Tolman,  New 
York  City ;  Dr.  Henry  P.  Walcott,  Boston.  Mass. ;  Dr.  William  H.  Welch,  Balti- 
more, Md. ;  Prof.  P.  F.  Wesbrook.  Minneapolis,  Minn. ;  Talcott  Williams,  Philadel- 
phia, Pa. ;   President,   Robert   S.   Woodward,   Washington,   D.   C. 

(322) 


Work  of  the  Committee  of  One  Hundred  79 

as  they  spread  over  state  boundaries,  must  be  known.  The  lack 
of  such  knowledge  has  been  an  added  incentive  to  the  Committee 
of  One  Hundred  to  ask  for  a  health  department  to  gather  national 
health  information.  Referring  to  a  map  which  the  government 
made  at  a  great  expense  to  show  where  the  best  beet  crops  might 
be  expected,  Dr.  Wiley,  chief  of  the  bureau  of  chemistry,  has 
commented  on  the  dearth  of  national  maps  on  more  vital  subjects. 
He  says: 

Our  government  needs  maps  of  vital  conditions  throughout  the  country. 
We  would  have  a  map  of  the  United  States  showing  where  the  cancer  belt  is, 
where  the  greatest  tuberculosis  area  is,  where  the  typhoid  area  lies,  what  is 
the  area  containing  men  and  women  of  the  finest  physiques.  Such  information 
would  be  of  illimitable  value  to  the  nation  in  any  intelligent  attempt  at  the 
reduction  of  disease,  and  would  save  millions  of  dollars  to  the  nation  now  lost 
by  unnecessary  sickness  and  unnecessary  premature  death. 

Meanwhile  the  committee  has  availed  itself  of  such  material 
as  exists  on  national  health  conditions,  and  has  endeavored  to  place 
this  material  in  the  hands  of  as  many  people  as  possible.  The 
object  of  the  committee  was  two-fold :  First,  to  give  ground  for 
a  popular  demand  for  a  National  Health  Department ;  second,  to 
set  the  people  thinking  on  health  subjects.  As  Dr.  Wiley  further 
says : 

If  we  have  never  had  a  Department  of  Health,  Congress  is  not  at  fault; 
it  is  the  fault  of  the  people  of  the  United  States.  They  are  perfectly  apathetic 
about  their  own  health.  They  go  about  their  work  day  after  day,  and  then 
when  a  break  in  health  comes,  they  submit  to  all  its  consequences  with  a  kind 
of  feeling  that  the  disaster  is  inevitable. 

An  American  Health  League  was  started  by  the  committee. 
The  membership  in  the  league  soon  numbered  25,000.  To  these 
people  and  to  the  press  literature  was  sent  on  the  prevention  of 
sickness  and  the  need  of  national  action.  In  all  the  committee  has 
issued  over  two-score  publications,  among  them  "National  Vitality," 
the  report  by  Professor  Irving  Fisher,  president  of  the  Committee 
of  One  Hundred,  as  a  member  of  President  Roosevelt's  Conserva- 
tion Commission.  This  report,  which  was  commended  by  eminent 
scientists,  showed  that  out  of  the  entire  population  1,500,000  die 
annually,  and  of  this  number  nearly  half  (over  620,000)  die  many 
years  before  they  should ;  that  proper  precautions  would  save  those 

(323) 


8o  The  Annals  of  the  American  Academy 

years  of  life.  It  also  showed  that  there  are  constantly  3,000,000 
sickbeds  in  the  country,  and  that  if  hygienic  knowledge  now  avail- 
able were  used,  at  least  one-half  of  these  people  might  be  among 
the  well,  instead  of  among  the  sick.  But  besides  the  knowledge 
which  already  exists  in  regard  to  the  nature  of  diseases,  Professor 
Fisher  brings  out  in  his  report  that  much  more  knowledge  is  needed 
to  explain  the  causes  of  many  diseases.  For  obtaining  such  informa- 
tion and  for  spreading  it  among  the  people,  a  National  Health 
Department  would  be  effective. 

This  conservation  report  on  "National  Vitality,"  was  printed 
in  several  large  editions  by  the  United  States  Senate,  at  the  sug- 
gestion of  Senator  Robert  L.  Owen,  who  has  actively  championed 
the  National  Department  of  Health  movement.  Copies  of  the 
report  were  spread  throughout  the  country,  and  have  furnished  a 
large  part  of  the  committee's  educational  campaign. 

A  magazine  called  "American  Health,"  was  published  by  the 
committee  in  the  beginning  of  its  work.  After  a  few  issues  of  this 
magazine,  however,  the  committee  succeeded  in  enlisting  the  direct 
co-operation  of  "McClure's  Magazine,"  "World's  Work,"  "The 
Survey,"  "The  Dietetic  and  Hygienic  Gazette,"  and  "Good  Health." 
When  this  was  accomplished,  the  committee's  own  magazine  was 
discontinued.  Many  other  magazines  have  directly  co-operated  in 
the  committee's  work. 

Since  the  results  for  which  the  committee  is  working  are  a 
matter  of  vital  consequence  to  life  insurance  companies  from  a 
business  standpoint,  it  was  apparent  to  the  committee  from  the 
beginning  that  such  companies  could  be  a  powerful  aid  in  accom- 
plishing those  results.  At  a  meeting  of  the  Association  of  Life 
Insurance  Presidents,  in  February,  1909,  Professor  Irving  Fisher 
read  a  paper  on  "The  Economic  Aspect  of  Lengthening  Human 
Life."  A  "Human  Life  Extension  Committee"  was  then  appointed. 
Since  this  meeting,  the  life  insurance  companies  have  entered  more 
actively  into  the  health  campaign.  Health  educational  departments 
have  been  established  in  many  of  the  companies,  medical  examina- 
tions have  been  increased,  sanatoria  have  been  built,  and  definite 
steps  have  been  taken  to  aid  in  obtaining  national  action  in  behalf 
of  health.  The  life  insurance  companies,  therefore,  are  to-day 
among  the  most  powerful  agencies  for  the  betterment  of  health  in 
this  country.     In  a  recent  paper  on  the  subject,  Professor  Fisher 

(324) 


Work  of  the  Committee  of  One  Himdred  8i 

reviewed  the  progress  which  the  insurance  companies  have  made 
in  health  work.     He  said: 

At  present  the  movement  has  only  just  begun;  although  it  has,  I  believe, 
gone  far  enough  to  demonstrate  its  wisdom.  The  Metropolitan  has  established 
a  consumptive  sanatorium  in  the  face  of  much  opposition  and  in  spite  of 
an  adverse  decision  at  first  by  the  Insurance  Commissioners  of  New  York 
State  as  to  their  right  to  do  so;  it  has  engaged  visiting  nurses  to  co-operate 
with  visiting  nurses'  associations  in  certain  cities  to  care  for  its  bed-ridden 
policyholders;  it  has  established  a  health  magazine  to  distribute  health  lit- 
erature among  its  policyholders — which  magazine  is  made  available  to  15,- 
000,000  readers,  or  one-sixth  of  the  population  in  the  United  States;  and 
it  has  endorsed  in  several  ways  and  on  several  occasions  the  movement 
for  a  National  Department  of  Health. 

The  Provident  Life  Assurance  Company  has  established  a  health  bureau 
which  performs  two  functions,  one  of  issuing  bulletins  of  health  information 
among  its  policyholders,  the  other,  of  granting  to  those  who  choose,  free 
medical  examinations.  At  first  these  free  examinations  were  to  occur  every 
two  years,  but  the  results  were  immediately  found  to  be  so  satisfactory  in 
holding  off  the  Grim  Reaper,  who  was  creeping  upon  his  victims  unawares, 
that  the  interval  for  periodical  examinations  has  been  reduced  to  one  year. 

The  New  York  Life  Insurance  Company  has  taken  a  hand  in  the  effort 
to  improve  and  purify  the  milk  supply  of  New  York  City. 

Mr.  Robert  L.  Cox,  counsel  for  the  Association  of  Life  Insurance  Presi- 
dents, states  that  "practically  all  of  the  companies  represented  in  the  Associa- 
tion of  Life  Insurance  Presidents  are  giving  their  moral  support  to  the  move- 
ment for  the  prolongation  of  human  life.  In  addition,  many  of  them  are  doing 
practical  educative  work.  Measured  by  number  of  policies  in  force,  the 
association  companies  cover  seventy-eight  per  cent  of  the  field  of  American 
companies,  having  21,700,000  policies  out  of  a  total  of  about  28,000,000.  The 
association  companies  engaging  in  individual  work  along  health  betterment 
lines  have  seventy-three  per  cent  of  the  total  number  of  policies  in  force,  or 
20,500,000. 

There  is  another  group  of  companies  in  the  association  which  goes 
beyond  the  body  of  policyholders  in  its  health  promotion,  activities.  They 
advise  impaired  applicants  for  insurance  as  to  their  physical  condition  and 
make  suggestions  to  aid  them.  There  are  four  companies  in  this  group. 
Two  of  them,  in  the  East,  have  a  total  of  86,000  policies.  Another  is  a 
flourishing  Middle  West  company  that  has  about  150,000  policies.  The  fourth 
is  a  young  and  conservative  Southern  company  with  7,200  policies. 

One  of  the  Connecticut  companies  has  published  suggestions  as  to  health 
reform  in  its  magazines  to  agents.  Two  other  companies — one  of  Massachu- 
setts and  the  other  of  California — are  considering  active  work  in  the  future. 

The  fraternal  societies  have  entered  the  campaign.  Their  journal,  the 
"Western  Review"  now  has  a  department  especially  devoted  to  the  public 
health.    Fraternal  insurance  companies  have  also  in  several  instances  estab- 

(325) 


82  The  xinnals  of  the  American  Academy 

lished  sanatoria,  and  have  attempted  in  other  ways  to  lengthen  lives  and 
decrease  death  claims. 

The  accident  companies  have,  I  understand,  for  some  time,  aided  in  getting 
state  laws  passed  to  prevent  accidents  to  life  and  limb. 

Finally,  health  insurance,  on?  of  the  youngest  forms  of  insurance,  has 
made  a  beginning  in  the  field  of  prevention.  The  Loyal  Protective  Insurance 
Company  has,  within  the  last  few  months,  established  a  health  bureau  to  issue 
bulletins  and  conduct  a  sort  of  correspondence  school  of  health  information. 
Considering  the  fact  that  few,  if  any,  of  the  existing  insurance  companies  have 
been  engaged  in  health  insurance  for  more  than  fourteen  years,  their  present 
entrance  into  the  field  of  prevention  is  unusually  prompt.  Personally  I 
believe  that  in  health  and  accident  insurance — and  especially  in  health  insur- 
ance— there  are  gigantic  possibilities  of  profit.  I  use  the  term  profit  rather 
than  philanthropy  in  recognition  of  the  fact  that  insurance  companies  as  such 
have  no  business  to  undertake  philanthropic  work  except  when  it  is  profitable. 
In  the  end  the  money  gains  made  by  the  insurance  companies  by  reducing 
mortality  and  invalidity  will  be  shared  by  the  public  in  reduced  premiums. 

In  the  matter  of  enlisting-  government  aid,  the  committee  has 
been  active  in  several  states.  It  has  aided  health  legislation,  notably 
the  law  in  Connecticut  for  the  "Sterilization  of  Degenerates." 

The  committee  has  also  laid  the  foundations  for  national  health 
legislation.  In  the  beginning  of  its  work,  ex-President  Cleveland 
sent  a  letter  of  endorsement.  Then  came  the  endorsements  of 
Presidents  Roosevelt  and  Taft,  and  of  Mr.  Bryan.  Both  political 
parties  put  national  planks  in  their  platforms.  Many  noted  men 
endorsed  the  movement  and  worked  in  its  behalf.  The  governors 
of  most  of  the  states  expressed  themselves  as  favoring  the  estab- 
lishment of  a  National  Health  Bureau  or  Department.  National 
societies  favored  the  movement,  and  passed  resolutions  endorsing 
it.  The  Grange  endorsed  it.  The  United  Mine  Workers  and  other 
labor  organizations  endorsed  it.  Educational  institutions,  boards 
of  health,  civic  associations,  women's  clubs — all  heartily  endorsed 
the  committee's  work.  Boards  of  trade  throughout  the  country 
took  up  the  movement,  recognizing  that  health  plays  an  important 
part  in  the  prosperity  of  a  community.  The  country  can  now  be 
said,  therefore,  to  be  awake  to  the  need  of  national  action  for  the 
suppression  of  disease. 

The  Honorable  George  Shiras,  III,  a  member  of  the  committee, 
made  an  exhaustive  study  of  the  question  of  constitutionality  of  a 
National  Health  Department,  and  reported  favorably  on  it. 

The  first  national   bills   of   importance  that   came   under   the 

(326) 


Work  of  the  Committee  of  One  Hundred  83 

consideration  of  tne  committee  were  Senate  bills  6101  and  6102 
and  their  equivalents  in  the  House.  These  bills  aimed  to  increase 
the  salaries  of  officers  in  the  Public  Health  and  Marine  Hospital 
Service,  and  to  enlarge  the  scope  of  their  v^^ork.  The  merits  of  the 
bills  were  given  thorough  investigation  by  the  executive  and  the 
legislative  sub-committees  of  the  Committee  of  One  Hundred. 
After  due  deliberation,  the  committee  decided  to  withhold  approval 
(except  as  to  the  increase  in  salaries),  and  submitted  to  the  Presi- 
dent its  own  plan  for  increasing  the  efficiency  of  the  federal  health 
service.  Instead  of  enlarging  the  scope  of  the  present  Public  Health 
and  Marine  Hospital  Service,  which  might  result  in  duplication  of 
work  already  being  done  in  other  bureaus  of  the  government,  the 
committee  recommended  that  all  the  federal  health  agencies  be 
concentrated  into  one  department,  instead  of  being  scattered,  as  they 
are  now,  in  various  departments. 

The  President  then  appointed  a  "Commission  on  the  Organi- 
zation of  the  Scientific  Work  of  the  Government."  This  commis- 
sion consisted  of  Charles  Walcott.  chairman  (director  of  the  Smith- 
sonian Institute),  James  R.  Garfield,  W.  L.  Capps,  William  Crozier 
and  GifFord  Pinchot.  They  confirmed  the  recommendations  of  the 
committee,  stating  that  "there  exists  a  lack  of  co-ordination  and 
eflfectiveness  [among  the  bureaus  doing  public  health  work]  that  can 
only  be  overcome  by  administrative  supervision  in  one  department." 

In  the  fall  of  1909  President  Taft  took  up  the  subject  of 
co-ordinating  the  existing  federal  health  agencies,  after  having 
repeatedly  favored  the  idea  in  his  public  utterances.  He  had  various 
plans  suggested  for  the  improvement  of  the  federal  health  service. 
These  were  submitted  to  the  Committee  of  One  Hundred,  and  expert 
opinions  were  obtained  from  outside  sources.  None  of  these  plans, 
however,  satisfied  the  President  or  the  ccmmittee. 

New  health  bills  were  introduced  in  Congress,  until,  during  the 
session  of  1910,  there  were  no  less  than  six  public  health  bills  to 
which  the  Committee  of  One  Hundred  gave  consideration.  One 
bill,  introduced  by  Congressman  Simons,  aimed  "to  further  protect 
the  public  health."  imposing  additional  duties  on  the  Public  Health 
and  Marine  Hospital  Service.  Another  bill,  introduced  by  him, 
aimed  to  "establish  a  Department  of  Public  Health,"  this  depart- 
ment to  be  supervised  by  a  director-general  of  public  health  appointed 
by  the  President,  all  divisions  of  the  government  work  relating  to 

(327) 


84  The  Annals  of  the  American  Academy 

public  health,  except  those  in  the  War  and  Navy  departments,  to 
be  combined  in  one  department.  Congressman  Hanna  introduced 
another  bill  "to  establish  a  Department  of  Public  Health."  This 
provided  for  a  secretary  of  health,  who  should  have  a  seat  in  the 
Cabinet.  Congressman  Mann  introduced  the  bill  "providing  for 
a  public  health  service."  This  was  the  plan  to  change  the  name 
of  the  Public  Health  and  Marine  Hospital  Service  and  to  enlarge 
its  scope.  He  also  introduced  another  bill  to  establish  a  bureau 
of  health  within  the  Department  of  Commerce  and  Labor  "to  per- 
form the  functions  now  exercised  by  the  Public  Health  and  Marine 
Hospital  Service  and  the  division  of  foods  and  drugs  of  the  bureau 
of  chemistry."  Senator  Owen  introduced  a  bill  to  establish  a  Depart- 
ment of  Public  Health  under  the  head  of  a  secretary  who  should 
be  a  member  of  the  President's  Cabinet.  After  giving  due  con- 
sideration to  all  of  the  bills,  and  to  the  subject  of  the  advisability 
of  drafting  a  bill  of  its  own,  the  Committee  of  One  Hundred 
decided  to  endorse  the  principle  of  the  Owen  bill,  although  not  com- 
mitting itself  to  its  details. 

The  national  health  movement  has  been  powerfully  supported 
by  many  members  of  the  House  and  the  Senate.  Upon  taking  a  poll 
of  Congress,  the  committee  found  that  there  exists  predominating 
sentiment  in  favor  of  increasing  the  efficiency  of  the  federal  work 
concerned  with  conserving  the  human-life  assets  of  the  country. 

One  problem  before  the  committee  was  the  question  of  estab- 
lishing a  Department  of  Health  instead  of  a  bureau.  The  original 
aim  of  the  committee  was  a  department,  but  President  Roosevelt 
was  unwilling  to  enlarge  the  Cabinet  by  adding  a  Secretary  of 
Health.  In  order  to  obtain  the  President's  help,  the  committee 
withdrew  its  advocacy  of  a  department,  and  asked  for  only  a  new 
bureau  of  health,  to  be  placed  within  one  of  the  present  departments. 
This  change  was  adopted,  not  because  anything  less  than  a  depart- 
ment is  needed  to  carry  on  properly  the  work  of  conserving  the 
lives  of  91,000,000  people,  but  as  a  step  in  the  right  direction. 

When  President  Taft  came  into  office,  it  was  found  that  he 
was  less  opposed  to  enlarging  the  Cabinet.  Upon  the  appearance 
of  the  Owen  bill  for  a  Department  of  Health,  the  committee  decided 
to  endorse  the  principle  of  the  bill.  In  regard  to  this  question  of 
a  department  versus  a  bureau,  Senator  Owen  says: 

(328) 


Work  of  the  Committee  of  One  Hundred  85 

We  have  had  bureaus  affecting  the  public  health  for  one  hundred  years. 
They  are  scattered  in  eight  departments.  They  have  been  disconnected  and 
vfcfithout  co-ordination.  They  have  even  been  jealous  of  each  other,  the  one 
nullifying  and  hampering  the  work  of  another.  They  have  been  without  a 
responsible  head  because  of  this  subdivision  and  because  the  chief  of  the  most 
important  of  these  bureaus,  the  Surgeon-General  of  the  Public  Health  and 
Marine  Hospital  Service,  can  not  express  an  opinion  or  give  information 
until  he  has  consulted  the  Secretary  of  the  Treasury — a  system  that  is  abso- 
lutely ridiculous. 

The  Secretary  of  the  Treasury  was  not  selected  as  a  Cabinet  officer 
because  of  his  knowledge  of  the  public  health,  but  because  he  was  an  expert 
on  finance.  At  present  our  Cabinet  expert  on  finance  directs  government 
activities  in  controlling  bubonic  plague,  and  the  board  of  trade  and  a  few 
commercialized  physicians  of  San  Francisco  would  be  more  important  in  his 
eyes  in  all  human  probability  than  the  chief  of  one  of  his  subordinate  bureaus ; 
at  all  events  this  was  true  as  to  a  previous  Secretary. 

Senator  Owen  cites  an  instance  when  local  commercial  interests 
went  over  the  head  of  the  chief  of  a  health  bureau,  as  a  consequence 
of  which  public  health  had  to  suffer. 

Upon  the  appearance  of  Senator  Owen's  bill,  and  after  the 
stirring  speech  which  he  made  on  this  subject  in  the  Senate,  a 
new  faction  appeared.  This  sprang  up  suddenly,  apparently  with 
plenty  of  money  at  its  command,  and  put  in  the  newspapers  paid 
advertisements,  which  contained  misleading  statements  designed 
to  convince  readers  that  the  Owen  bill  proposed  to  establish  a 
department  of  healing,  that  only  doctors  of  one  school  of  medicine 
would  be  allowed  to  practice,  and  that  the  "medical  freedom"  of 
those  of  all  other  schools  would  be  restricted.  As  there  is  no  part 
in  the  plan  for  a  National  Department  of  Health,  which  seems  to 
justify  such  a  perverted  view  of  the  national  health  movement,  the 
Committee  of  One  Hundred  has  endeavored  to  look  into  the  source 
of  the  opposition.  The  committee  has  found  that  it  is  aimed  at 
the  American  Medical  Association,  which  happens  to  be  one  of  the 
many  endorsers  of  the  Department  of  Health  idea.  The  American 
Medical  Association  has  maintained  a  department  for  investigating 
the  ingredients  of  certain  patent  medicines,  making  public  the  facts 
regarding  the  misrepresentations  made  in  their  behalf  and  the  harm- 
ful results  from  using  those  that  contained  injurious  drugs.  Such 
a  proceeding  on  the  part  of  the  American  Medical  Association  has 
not  only  antagonized  the  patent  medicine  interests,  but  has  antago- 
nized those  doctors  who  have  been  in  the  habit  of  prescribing  such 

(329) 


86  The  Annals  of  the  American  Academy 

medicines  for  their  patients.  The  cry  of  these  people  for  "medical 
freedom"  has  been  caught  up  by  a  number  of  unsuspecting  people, 
however.  Some  of  the  Christian  Scientists,  for  instance,  are  said 
to  be  enlisted.  Ignoring  the  fact  that  the  real  issue  is  whether  or 
not  the  government  shall  take  steps  to  prevent  the  needless  sick- 
ness from  which  this  country  is  now  suffering,  these  people  appar- 
ently accept  the  present  amount  of  sickness  as  inevitable,  and  center 
their  attention  on  who  shall  get  the  business  of  treating  it.  Presi- 
dent Taft  referred  to  these  misrepresentations  in  his  message  to 
Congress  in  December,  1910.    He  said: 

In  my  message  of  last  year  I  recommended  the  creation  of  a  bureau  of 
health,  in  which  should  be  embraced  all  those  government  agencies  outside 
of  the  War  and  Navy  departments  which  are  now  directed  toward  the  pre- 
servation of  public  health  or  exercise  functions  germane  to  that  subject. 
I  renew  this  recommendation.  I  greatly  regret  that  the  agitation  in  favor  of 
this  bureau  has  aroused  a  counter  agitation  against  its  creation,  on  the  ground 
that  the  establishment  of  such  a  bureau  is  to  be  in  the  interest  of  a  particular 
school  of  medicine.  It  seems  to  me  that  this  assumption  is  wholly  unwar- 
ranted, and  that  those  responsible  for  the  government  can  be  trusted  to 
secure  in  the  personnel  of  the  bureau  the  appointment  of  representatives  of 
all  recognized  schools  of  medicine,  and  in  the  management  of  the  bureau 
entire  freedom  from  narrow  prejudice  in  this  regard. 

Meanwhile  the  country  is  interested  in  the  facts  regarding 
achievements  in  the  prevention  of  sickness  that  have  been  made  in 
different  parts  of  the  United  States,  and  in  Panama  and  the  depen- 
dencies, by  the  adoption  of  sanitary  measures. 

Congressman  Mann  has  now  introduced  in  the  House  a  bill 
to  change  the  name  of  the  Public  Health  and  Marine  Hospital 
Service  to  the  Public  Health  Service,  and  to  enlarge  its  scope.  The 
committee  has  decided  to  oppose  this  bill,  as  being  an  avoidance  of 
the  demand  for  a  consolidation  of  the  health  activities  of  the  gov- 
ernment. The  committee  is  continuing  its  endeavors  to  unite  the 
powers  of  the  nation  against  the  enemies  of  health,  confident  of 
the  support  of  all  who  are  guided  by  reason  and  humanity. 


(330) 


PUBLIC  HEALTH  MOVEMENT  ON  THE  PACIFIC  COAST 


By  Sarah  I.  Shuey,  M.  D., 
Oakland,  Cal. 


It  is  appreciated  here,  as  elsewhere,  that  the  great  motive 
power  back  of  this  world-wide  health  movement  is  the  discovery 
of  the  germ  theory  of  disease  through  the  efforts  of  our  scientists, 
to  whom  the  deepest  gratitude  is  felt,  and  to  whom  the  highest 
praise  must  be  given.  The  proof  of  the  appreciation  of  the 
work  can  be  best  expressed  by  spreading  this  new  gospel.  An 
eminent  surgeon  says,  that  more  has  been  accomplished  in  the 
last  thirty  years  than  in  thirty  centuries  before. 

Chemistry,  physiology,  bacteriology,  hygiene,  sanitation,  diet- 
etics, psychology,  philanthropy,  jurisprudence,  sociology  and  crim- 
inology are  giving  the  required  knowledge  that  only  needs  practical 
application  to  bring  to  humanity,  health  in  its  widest  and  truest  sense, 
the  health  that  enables  man  to  develop  the  highest  and  best  of  which 
he  is  capable,  in  his  physical,  mental  and  moral  nature.  Undoubtedly 
the  first  great  step  has  been  the  tuberculosis  campaigns,  which  have 
stimulated  greater  activity  in  overcoming  other  diseases,  especially 
those  of  an  infectious  nature.  The  tuberculosis  associations  have 
been  active  throughout  the  West. 

A  special  interest  was  awakened  in  the  State  of  Washington 
by  the  Tuberculosis  and  Public  Health  Exhibit  at  the  Alaska- 
Yukon-Pacific  Exposition,  held  in  Seattle,  in  1909.  Enthusiastic 
local  leagues  were  formed  in  many  counties.  There  is  an  active 
state  society.  W^hile  Washington  has  an  excellent  law,  provid- 
ing for  the  reporting  of  cases,  and  for  disinfection,  this  law  has 
been  a  dead  letter  from  the  first ;  that  is,  for  eleven  years,  for  lack 
of  funds.  Strenuous  eflPorts  will  be  made  at  the  present  Legis- 
lature to  procure  an  appropriation. 

In  Oregon,  $10,000  has  been  expended  through  the  Visiting 
Nurses'  Association  in  caring  for  indigent  tuberculars.  A  state 
sanitarium,  well  equipped,  accommodates  150  patients.  The  Peni- 
tentiary and  Insane  Asylum  have  separate  outdoor  pavilions  for 
their  tubercular  inmates. 

California   has    a    state    association,   which    also    has   been 

(33O 


88  The  Annals  of  the  American  Academy 

greatly  limited  by  lack  of  funds.  Seventy-five  per  cent,  of  all 
the  money  reaching  its  treasury  has  been  received  from  Los 
Angeles.  The  great  problem  in  California  is  not  of  the  native, 
born,  who  acquire  the  disease,  but  the  penniless  consumptives 
who  come  in  such  advanced  stages  that  cure  is  impossible. 
Fifty  per  cent,  of  the  cases  belong  to  this  class.  So  acute  did 
conditions  become  a  few  years  ago  that  a  conference  of  social 
workers,  through  the  Associated  Press,  sent  an  appeal  to  Eastern 
organizations  to  refrain  from  sending  their  advanced  and  penni- 
less cases.  Many  of  the  Southern  California  fruit  ranches  are 
largely  colonized  by  consumptives,  and  many  have  been  per- 
manently cured.  In  Banning,  65  per  cent,  of  the  inhabitants 
have  settled  there  on  account  of  tuberculosis,  either  in  them- 
selves or  their  families.  California  has  no  public  sanatoria  for 
tuberculous  cases,  but  allows  a  dollar  a  day  for  each  patient 
to  charitable  institutions  caring  for  its  consumptives. 

To  Southern  California  belongs  the  credit  of  having  estab- 
lished the  first  charitable  sanatoria  for  consumptives — The  Red- 
land  Settlement,  at  Redland;  The  Barlow  Sanatorium,  Los 
Angeles;  The  Stehman  Sanatorium,  of  Pasadena. 

At  one  of  the  insane  hospitals  a  wire  enclosed  yard  has  been 
furnished  for  outdoor  life  for  the  inmates.  So  much  is  it  ap- 
preciated that  a  mere  suggestion  that  he  will  have  to  go  indoors 
if  he  is  boisterous  or  noisy,  causes  the  patient  to  become  docile 
and  tractable.  Large  numbers  of  educational  pamphlets  in 
difiFerent  languages  have  been  distributed  by  the  tuberculosis 
societies. 

Through  the  San  Francisco  Association  for  the  Study  and 
Prevention  of  Tuberculosis,  the  supervisors  have  passed  a  most 
stringent  law  which  places  San  Francisco  unquestionably  in  the 
foremost  rank  so  far  as  tuberculous  legislation  is  concerned. 
Lectures  have  been  given  to  unions,  fraternal  organizations, 
settlement  workers,  mother's  clubs  and  in  schools  and  churches. 
Thousands  of  circulars  have  been  distributed  at  these  lectures. 

Tuberculosis  clinics  are  held  in  several  of  the  large  cities  on 
the  coast.  Tuberculosis  exhibits  by  means  of  demonstration 
cars,  lantern  slides  and  moving  pictures,  have  been  most  fruitful 
agents  in  educating  the  public,  especially  in  California. 

The  increased  demand  for  certified  milk  is  a  direct  result 

(332) 


Public  Health  Movement  on  Pacific  Coast  89 

of  this  education.  A  rather  unusual  sign,  "Do  not  spit  here," 
is  placed  high  upon  the  wall  in  the  assessor's  office  in  one  of  our 
large  cities.  Its  position  at  once  arrests  the  attention  and 
creates  a  smile,  for  not  even  the  most  inveterate  "spitter"  would 
choose  such  a  place,  but  it  is  an  effective  deterrent. 

In  the  use  of  moving  pictures  many  health  subjects  are  il- 
lustrated ;  for  example,  the  dangers  of  impure  milk,  of  the  fly  evil, 
of  the  malarial  mosquito  and  the  bubonic  flea.  Apropos  of  the 
use  of  these  novel  films,  this  little  jingle  by  Gertrude  McKensie 
is  transcribed : 

"No  more  we'll  seek  the  picture  shows 

To  drive  away  dull  care, 
To  see  how  Casey  led  the  goat, 

Or  watch  the  county  fair; 
No  more  upon  the  screen  we'll  see 

How  Wilbur  Wright  can  fly — 
We'd  rather  watch  the  ptomaines  jump, 

And  see  the  germs  waltz  by. 

"No  more  we'll  seek  the  far  North  Pole 

With  Peary  or  with  Cook, 
Or  scour  the  plains  with  Broncho  Bill — 

We'll  watch  the  hookworm  hook. 
We'll  no  more  laugh  to  see  portrayed 

The  pranks  of  little  Willie — 
We'll  watch  the  microbe  do  its  stunts, 

And  cheer  the  new  bacilli." 

California  has  several  open-air  schools  for  tuberculous  chil- 
dren in  Los  Angeles,  San  Francisco  and  Oakland.  Dr.  N.  K. 
Foster,  the  medical  inspector  of  the  Oakland  schools,  California, 
has  furnished  some  interesting  data,  showing  the  average  gain  in 
weight  of  a  class  of  tubercular  children  out-of-doors,  and  that  of 
a  class  of  the  same  grade  indoors.  Each  child  of  the  two  classes 
was  weighed  at  the  beginning  of  the  school  term,  and  again  at 
the  end  of  the  term,  five  months  later.  Comparison  of  the  weights 
for  the  indoor  class  of  normal  children  with  those  of  the  out- 
door tubercular  children  showed  an  average  gain  for  the  tuber- 
cular child  over  that  of  the  normal  child  of  1.37  pounds. 

Despite  the  knowledge  gained,  of  the  value  of  fresh  air  and 
its  application  in  the  case  of  the  tuberculous,  there  is  the  greatest 
disregard  of  its  use  as  a  prevention  of  disease.  It  really  amounts 
to  criminal  negligence  when  one  considers  the  poorly  ventilated 
school-rooms,  in  which  children  are  obliged  to  spend  four  or  five 
hours  a  day.     Scarcely  a  church,  lecture  hall,  theater,  railway 

(333) 


90  The  Annals  of  the  American  Academy 

coach,  or  any  indoor  place  where  people  congregate  that  does  not 
soon  become  stuffy,  close  and  oppressive.  The  hope  of  the 
future  is  in  the  child,  and  common  justice  demands  that  he. 
should  not  be  subject  to  the  deleterious  influences  of  impure  air, 
dangerous  at  any  period  of  life  and  especially  to  the  growing 
child.  Though  insidious,  it  may  prove  as  great  a  menace  in 
undermining  the  system  in  the  formative  years  of  life  as  some  of 
the  dreaded  infectious  diseases  of  childhood.  One  would  shrink 
with  loathing  and  disgust  from  taking  again  into  the  body  the 
waste  from  the  intestinal  canal  or  urinal  tract,  yet  vitiated,  pol- 
luted, poisonous  exhalations  from  the  lungs  are  constantly  being 
rebreathed  in  poorly  ventilated  rooms. 

A  few  years  ago  a  prominent  architect  of  large  experience 
in  California  said  that  there  was  one  perfectly  ventilated  building 
in  the  State,  and  that,  a  small  bank  in  Woodland.  In  response 
to  the  query,  whether  the  laws  of  mechanics  had  been  applied 
successfully  for  satisfactory  ventilation,  he  replied,  "Yes,  perfectly." 
In  this  bank  the  fresh  air  entering  the  building  is  forced  to  pass 
through  a  sheet  of  water,  which  removes  impurities,  and  cools 
the  air  in  summer,  and  warms  it  in  winter.  The  expense  of  in- 
stalling the  ventilating  system  was  $5000.  A  few  days  ago  the 
same  architect  was  asked  if  the  Woodland  bank  was  still  the 
only  well-ventilated  building  in  California.  The  reply  was, 
"There  are  now  many  public  buildings  well  equipped,  some 
theaters,  few  churches,  but  no  homes.  Unfortunately,  in  many 
of  the  buildings  provided  with  an  adequate  ventilating  system 
the  supervision  is  faulty,  especially  in  the  school  buildings.  The 
teacher,  deeply  absorbed  in  other  matters,  is  the  last  one  to  have 
charge  of  the  ventilating,  and  few  janitors  are  equal  to  the  re- 
sponsibility. No  engineer,  no  matter  how  perfect  his  machine, 
would  think  it  could  be  run  by  one  not  trained.  At  first  the  ex- 
pense of  installing  the  ventilating  plant  was  at  fault,  and  now 
the  expense  of  supervising  and  operating  the  plant  is  the  cause 
of  bad  air  in  the  school-rooms." 

Perhaps  no  one  has  done  more  of  late  than  the  psychologist 
in  discovering  physical  handicaps  in  his  endeavor  to  determine 
the  degree  of  mental  deficiency  in  the  backward  child.  The  de- 
tection of  physical  defects,  or  deviations  from  the  normal,  in  their 
incipiency  is  not  often  permitted  the  physician,  because  his  ad- 

(334) 


Public  Health  Movement  on  Pacific  Coast  9I 

vice  IS  rarely  sought  until  defects  resulting  from  disease  have 
advanced  so  far  as  to  be  apparent  to  the  laity.  So  at  the  same 
time  that  the  public  is  being  educated,  the  physician  is  stimulated 
to  use  every  means  available  to  obtain  an  early  and  correct 
diagnosis. 

There  is  no  work  in  the  West  comparable  in  its  entirety  to 
that  being  done  in  the  University  of  Pennsylvania  in  the  Psycho- 
logical Clinic,  under  the  direction  of  Dr.  Lightner  Witmer.  One 
sees  in  this  clinic  the  results,  often  most  gratifying,  of  correcting 
defective  sight  or  hearing  or  from  removing  impacted  or  dis- 
eased teeth,  or  adenoids  and  tonsils,  and  overcoming  digestive 
disturbances ;  any  one  of  these  conditions,  in  different  cases  may 
reveal  the  tremendous  influence  of  a  physical  disability,  in  ar- 
resting normal  mental  or  moral  development.  Juvenile  court 
judges,  probation  officers,  and  social  workers,  all  begin  to  ap- 
preciate the  deterrent  and  perverting  effect  of  physical  troubles 
upon  the  normal  health  of  the  child.  Neither  is  there  on  the 
Pacific  Coast,  except  in  Los  Angeles,  anything  that  approaches 
the  extraordinary  "team  work"  done  in  Boston  and  Philadelphia, 
i.  e.,  the  co-operation  of  specialists  in  medicine,  oculists,  aurists,  neu- 
rologists and  dentists,  with  the  social  workers,  the  probation  offi- 
cers and  the  public  hospitals. 

The  state  board  of  health  of  California  has  made  gonorrhea 
and  syphilis  reportable,  the  same  as  other  infectious  diseases. 
It  has  the  distinction  of  being  the  first  State  to  inaugurate  such 
a  measure.  When  it  is  considered  how  many  innocent  ones  suf- 
fer through  this  disease,  it  is  appalling  and  too  much  cannot 
be  said  of  the  necessity  of  enlightenment  to  avert  the  evil  in 
the  future.  It  is  certain  that  ignorance  of  the  infectious  nature 
of  sexual  diseases  on  the  part  of  the  growing  young  man  and 
the  false  belief  that  his  physical  well-being  requires  sexual  grati- 
fication, are  the  principal  causes  for  his  downfall.  Grandin 
states  it  strongly,  "Man,  largely  through  ignorance  of  the 
calamities  following  the  misuse  of  this,  the  reproductive  instinct, 
has  converted  it  into  one  for  the  extermination  of  the  species." 
But  by  far  the  most  potent  agents  in  the  continuance  of  the 
evil  are  the  imperfect  laws  which  license  prostitution  and  require 
examination  of  the  women  prostitutes  only,  allowing  men  to 
go  free.    In  view  of  the  infectious  nature  of  sexual  diseases,  ex- 

(335) 


92  The  Annals  of  the  American  Academy 

termination  of  these  diseases  can  never  be  expected,  nor  even 
lessened,  with  such  laws.  It  is  true,  a  recent  remedy,  606,  or 
Salvargan,  claims  to  cure  syphilis.  Whether  this  will  counteract 
the  fear  of  infection,  remains  to  be  seen.  It  is  quite  certain 
that,  though  there  is  a  remedy  for  diphtheria  and  rabies,  it  is 
not  considered  a  good  reason  for  exposing  oneself  -to  these  dis- 
eases. 

Another  source  of  danger  to  the  young  man,  in  encouraging 
sexual  gratification,  is  the  use  of  alcohol.  Dr.  Prince  Morrow, 
of  New  York,  who  has  studied  the  subject,  says,  "Perhaps,  more 
than  any  other  agency,  alcohol  relaxes  the  moral  sense,  while 
it  stimulates  the  sexual  impulse." 

It  is  encouraging  to  note  in  this  connection  that  in  Cali- 
fornia 200  saloons  were  closed  during  1910;  that  68  precincts 
out  of  74  voted  "dry";  that  there  are  170  towns  and  65  in- 
corporated cities  from  which  the  traffic  has  been  banished. 
Eleven  counties  are  dry,  and  Los  Angeles  bars  the  saloon  from 
II  blocks  in  the  business  center.  California  is  given  the  credit 
of  having  the  most  effective  school  law,  passed  in  1909,  of  any 
State,  regarding  health  measures.  An  educator  especially  awake 
to  the  necessity  for  healthful  conditions  of  the  schoolroom,  well 
says,  "The  schools  furnish  an  unrivalled  opportunity  for  detect- 
ing and  checking  disease  and  defects  among  children."  It  will 
be  only  a  matter  of  a  short  time,  it  is  hoped,  before  medical 
inspection  will  be  in  every  school. 

The  bubonic  plague,  in  California,  the  truth  concerning  which 
the  daily  press  has  falsely  concealed  from  the  public,  has  yet  to 
be  fought.  In  the  light  of  present  knowledge,  its  absolute  eradi- 
cation in  the  State  depends  upon  extermination  of  the  ground 
squirrel.  Three  hundred  and  eighty-five  cases  of  plague-infected 
squirrels  were  found  in  the  fiscal  year  ending  June  30,  1910,  in 
the  Counties  of  Alameda,  Contra  Costa,  Monterey,  Merced,  San 
Bonito,  Santa  Clara,  Santa  Cruz,  Stanislaus  and  San  Luis  Obispo. 
There  was  a  death  of  one  human  reported  in  June,  1910,  due 
undoubtedly  to  infection  by  squirrel  fleas.  The  origin  of  the 
epidemic  in  1908  was  supposed  to  be  of  foreign  importation, 
now  it  is  known  that  the  infected  squirrels  were  the  cause.  Fed- 
eral officers  are  still  watching  the  seaports,  and  the  extermina- 
tion of  rats  goes  on.     Oregon,  fortunately,  has  never  had  an 

(336) 


Public  Health  Movement  on  Pacific  Coast  93 

invasion  of  bubonic  plague,  due  probably  to  the  fact  that  it  has 
no  easily  accessible  seaports,  as  in  Washington  and  California. 
Washington  has  had  no  plague  among  men  for  over  two  years, 
and  only  one  in  rats,  early  in  1910.  The  work  of  destroying 
rats  has  been  continued  by  the  United  States  Public  Health  and 
Marine  Hospital  Service  since  the  appearance  of  plague  there 
in  1907.  Washington  profited  by  the  disastrous  experience  of 
California  in  1903,  and,  by  energetic  measures,  promptly  and 
effectively  checked  the  outbreak.  It,  too,  realizes  the  danger 
that  may  come  to  it  through  the  infected  ground  squirrel  of 
California.  Besides  bubonic  plague,  the  other  Oriental  diseases, 
leprosy,  trachoma,  pellagra,  beri-beri,  amoebiasis  and  hookworm, 
are  being  carefully  watched  by  the  health  authorities  of  the  sea- 
ports. Cancer  and  poliomyelitis,  miscalled  infantile  paralysis  (for 
adults  are  also  victims),  the  cause  of  which  science  has  not  yet 
discovered,  continue  their  deadly  work  here,  as  elsewhere. 
California  takes  great  satisfaction  in  the  comparatively  small  ,A\^t./j, 
number  of  deaths  among  infants  from  dysinteric  and  diarrhoeal 
troubles.  The  cool  summers  on  the  coast,  and  the  absence  of 
humidity  in  the  interior,  are  the  beneficent  agents  lessening  these 
enteric  diseases  of  children. 

While  the  hygienic  laboratories  of  the  Pacific  Coast  are  do- 
ing effective  work,  they  are  much  handicapped  for  funds.  The 
death  rate  from  typhoid,  based  on  the  census  of  1910,  is  20  per 
100,000  in  California,  approximately  only  two-thirds  of  the 
United  States  rate.  Oregon  and  Washington  are  also  as  yet 
unable  to  control  their  water  supply  and  disposal  of  sewage  in 
rural  districts,  so  that  typhoid  still  continues  its  ravages,  a 
woeful  fact  in  this  enlightened  age. 

The  California  State  Health  Bulletin,  in  the  November  num- 
ber of  1910,  considers  the  necessity  of  a  compulsory  sanitary 
privy  law,  or  ordinance,  to  be  strictly  enforced  in  all  localities 
in  which  connection  with  a  sewer  system  is  not  enforced.  There 
is  also  presented  a  plan  for  a  sanitary  privy,  so  clear  in  detail 
that  any  14-year-old  boy  of  average  intelligence  and  mechan- 
ical ingenuity  could  build  it.  There  follows  minute  directions 
for  keeping  it  clean  and  how  to  dispose  of  the  excreta,  to  pre- 
vent pollution  of  drinking  water  and  vegetables  eaten  uncooked. 

The  playground  movement  has  been  enthusiastically  taken 

(337) 


94  The  Annals  of  the  American  Academy 

up  in  Washington  and  California.  Oregon  provides  each  school 
with  200  feet  square  of  playground.  The  playgrounds  are  super- 
vised i3y  voluntary  attendants,  there  being  no  salaried  employees.. 
California  has  the  distinction  of  having  the  first  state  play- 
ground association.  The  object  of  the  state  association  is  to 
promote  the  playground  movement,  in  all  its  phases,  throughout 
the  State,  to  promote  outdoor  life,  to  supervise  plays  and  to 
co-operate  with  school  authorities  in  a  more  spirited  use  of  all 
the  playgrounds.  The  University  of  California  and  the  normal 
schools  have  established  playground  courses  in  their  summer 
schools.  The  society  seeks  to  establish  a  spirit  of  "free  play, 
of  fair  play,  and  of  more  play" ;  and  to  educate  the  Common- 
wealth to  the  worth  of  stronger  boys  and  girls. 

In  April,  1910,  the  State  Board  of  Health  called  a  confer- 
ence of  the  welfare  organizations  of  California  to  meet  at  Sacra- 
mento. The  result  of  this  meeting  was  the  organization  of  the 
California  Public  Health  League.  Its  purpose  is  stated  in  the 
constitution  to  be  the  co-ordination  of  effort,  and  the  promotion 
of  economy  and  harmony  among  all  public  health  organizations 
and  agencies  in  California,  thus  correlating  the  important  work 
of  the  many  organizations  working  to  upbuild  California's  stand- 
ards of  health  and  happiness.  The  heartiness  with  which  the 
league  is  accepted  promises  well  for  the  ultimate  working  out 
of  its  purposes.  The  bulletins  sent  out  by  the  State  Board  of 
Health  of  California  deserve  especial  mention,  because  they 
show  a  decided  step  in  advance  in  their  scope  and  subject-matter. 

This  paper  would  not  be  complete  without  at  least  an 
enumeration  of  the  welfare  organizations  not  before  mentioned, 
and  which  are  strong  allies  in  health-conservation  work:  State 
Charities  Aid  and  Correction  Organization ;  California  Public 
Press ;  California  League  of  Municipalities ;  California  Teach- 
ers' Association ;  Women's  Christian  Temperance  Union ; 
Y.  M.  C.  and  Y.  W.  C.  Associations;  welfare  committees  of  the 
State  Federation  of  Labor ;  fraternal  organizations ;  chambers 
of  commerce ;  American  Red  Cross,  California,  chapters ;  the 
American  Medical  Association,  through  its  public  health  educa- 
tion committee ;  Association  of  Collegiate  Alumnae,  through  its 
certified  milk  fund  and  baby  hygiene  committee ;  California  Con- 
gress of  Mothers;  and  women's  clubs. 

(338) 


PROTECTING  PUBLIC  HEALTH  IN  PENNSYLVANIA 


By  Samuel  G.  Dixon,  M.D.,  LL.D., 
Commissioner  of  Health,  Commonwealth  of  Pennsylvania. 


The  present  State  Department  of  Health  of  Pennsylvania  was 
created  in  1905,  and  legislation  was  enacted  that  year  giving  the 
department  sufficiently  broad  and  general  powers  to  enable  the 
Commissioner  to  fully  enforce  all  necessary  health  regulations. 

Three  hundred  thousand  dollars  were  given  the  department  for 
the  two  years  1905  and  1906.  So  rapidly  did  the  work  grow  how- 
ever, that  in  1907  the  legislature  appropriated  to  the  department 
two  million  dollars.  Six  hundred  thousand  of  this  was  specifically 
set  aside  for  the  establishing  of  the  State  Sanatoria  for  Tubercu- 
losis, and  four  hundred  thousand  for  dispensaries  for  tuberculosis. 
Still  the  work  continued  to  grow.  People  gave  it  their  hearty 
support  and  in  1909  the  unprecedented  appropriation  of  two  million 
dollars  for  tuberculosis  and  one  million  dollars  for  general  health 
work,  was  given  the  State  Department  of  Health. 

Has  this  expenditure  of  public  funds  been  a  good  investment 
for  the  taxpayers  of  Pennsylvania?  To  answer  the  question  I  can 
simply  point  out  briefly  what  the  State  Department  of  Health  has 
been  doing  since  its  creation,  what  results  it  has  accomplished  and 
the  promise  of  fruition  in  the  future  for  the  seeds  already  sown. 

The  death  rate  in  Pennsylvania  fell  from  16.5  in  1906,  to  15.3 
in  1909.  That  does  not  sound  like  a  very  big  drop  when  recorded 
in  that  form.  But  when  our  more  than  seven  million  population 
is  considered,  it  means  a  saving  of  13,907  lives. 

In  four  years  the  death  rate  from  tuberculosis  has  fallen  from 
134  to  120  per  hundred  thousand  of  population.  That  means 
1,000  lives  a  year  saved  to  the  commonwealth. 

In  1906,  56.5  out  of  every  100,000  of  our  people  died  from 
typhoid  fever.  The  close  of  the  year  1907  saw  this  death  rate 
cut  down  to  50.3 ;  it  dropped  to  34.4  in  1908.  and  in  1909  to  23.9, 
cut  down  one-half  in  four  years.  Reckoned  in  the  number  of  pre- 
cious lives  saved,  this  means  that  had  the  death  rate  of  1906  pre- 

(339) 


96  The  Annals  of  the  American  Academy 

vailed  in  1909,  Pennsylvania  would  have  paid  in  tribute  to  this  dis- 
ease, 2,363  more  of  her  citizens. 

And  what  of  diphtheria,  the  terror  of  every  mother,  and  the . 
very  messenger  of  death  to  the  poverty-stricken  mother  who  can  not 
provide  antitoxin  for  her  sick  child?  The  state  in  its  beneficent 
charity  and  its  wise  effort  to  prevent  the  spread  of  disease,  has  driven 
back  this  foe.  Twenty  thousand  seven  hundred  and  ninety-four  little 
children,  stricken  down  with  diphtheria,  were  in  four  years  treated 
with  the  free  antitoxin  supplied  by  the  Department  of  Health's  650 
distributing  stations.  Without  antitoxin  8,743  of  these  children, 
according  to  recorded  mortality  rates,  would  have  died.  As  it  was 
only  1,765  died.  What  more  remarkable  saving  of  precious  life 
could  be  asked  as  a  result  of  a  wise  state  aid !  Six  thousand  nine 
hundred  and  sixty-eight  children  rescued  from  early  graves,  con- 
served to  Pennsylvania's  resources.  Moreover,  free  antitoxin  was 
also  given  in  15,125  cases,  mostly  children  who  had  been  in  con- 
tact with  the  disease.  All  but  a  very  few  of  these  were  absolutely 
protected  against  diphtheria. 

Four  years  ago  Pennsylvania  realized  the  fact  that  if  tubercu- 
losis was  to  be  conquered  the  state  campaign  against  it  must  be 
thoroughly  organized  and  conducted  on  a  comprehensive  scale.  To 
this  end  a  million  dollars  was  given  the  Department  of  Health  for 
tuberculosis  work  for  the  two  years  ending  May  31,  1910. 

With  the  humble  but  praiseworthy  state  camp  of  twenty-eight 
patients  at  Mont  Alto,  conducted  by  the  Forestry  Commission  as 
a  nucleus,  a  model  tuberculosis  village  was  started  on  this  sunlit 
plateau.  The  little  camp  has  now  grown  to  a  splendidly  equipped 
institution,  accommodating  eight  hundred  patients,  with  buildings 
now  under  construction  that  will  raise  the  capacity  to  over  twelve 
hundred.  Up  to  date  considerably  over  four  thousand  poor  con- 
sumptives, in  all  stages  of  the  disease,  have  been  treated  at  Mont 
Alto. 

The  Mont  Alto  Sanatorium  has  six  hundred  and  fifty  acres  of 
ground  situated  in  a  state  forestry  reservation  of  fifty-five  thousand 
acres.  The  buildings  are  on  a  plateau  of  the  Blue  Mountains,  six- 
teen hundred  feet  above  sea  level,  swept  by  pine  laden  breezes. 
The  cottages  for  the  early  and  moderately  advanced  cases  are 
designed  to  accommodate  eight  patients  each.  They  are  nearly 
square,  measuring  27  x  24  feet,  with  a  central  hall  5  feet  8  inches 

(340) 


Protecting  Public  Health  in  Pennsylvania  97 

in  width,  which  is  enlarged  in  the  center  for  heating  and  lavatory 
purposes.  Ventilation  is  secured  by  direct-indirect  steam  heating. 
The  loft  is  well  ventilated  to  keep  the  patients'  room  cooler  during 
the  summer  months.  Two  patients  occupy  each  room,  which  is  so 
arranged  as  to  secure  an  ample  supply  of  fresh  air,  with  propei 
protection  against  storms.  The  cottages  are  so  placed  that  each 
room  will  receive  the  maximum  of  the  sun's  rays  during  the  day. 

The  patients  rest  during  the  day  in  ample  pavilions,  instead 
of  porches  to  their  cottages  which  would  forbid  the  sun's  rays. 
The  dining  room  is  a  large,  well-constructed  building,  originally 
built  to  accommodate  500,  but  permitting  of  extensions  as  needed. 
The  infirmary  for  the  accommodation  of  the  incurable  cases  is 
beautifully  situated  in  the  pines,  but  apart  from  the  other  build- 
ings. There  are  bath  and  toilet  houses  at  convenient  distances,  and 
a  sewage  disposal  plant.  We  are  at  present  completing  a  number 
of  new  buildings  at  the  sanatorium,  including  additional  cottages, 
a  modern  dispensary,  nurses'  quarters,  and  a  separate  building  for 
children.  Here,  in  the  pure  air  and  glorious  sunshine,  Pennsyl- 
vania's consumptive  poor,  in  all  stages  of  the  disease,  are  receiving 
the  best  care  and  treatment  that  it  is  possible  to  get  anywhere. 

Some  weeks  ago  when  our  tuberculosis  exhibit  was  being  shown 
in  Pittsburg,  the  attendants  noticed  a  big,  strong,  husky  fellow 
pointing  out  the  features  of  the  model  Mont  Alto  buildings  to  the 
visitors.  Upon  inquiry  he  was  found  to  be  a  former  Mont  Alto 
patient  and  the  joy  of  life  and  restored  health  shone  in  his  face. 
He  was  only  a  type  of  many  another  who  has  won  his  fight  under 
the  state's  care.  In  many,  of  course,  the  disease  had  gone  too  far 
but  they  have  been  made  comfortable  and  happy  at  the  institution 
and  at  the  same  time  have  not  been  a  source  of  infection  to  others 
in  their  homes. 

Tucked  within  the  forest  and  thus  protected  from  the  winter 
winds,  but  enjoying  the  full  benefits  of  the  high  altitude,  the  new 
State  Sanatorium  for  Tuberculosis,  at  Cresson,  is  being  constructed 
by  the  State  Department  of  Health,  on  the  property  given  the  com- 
monwealth by  Andrew  Carnegie.  It  is  so  planned  that  four  wings 
may  be  constructed,  one  at  a  time,  as  needed,  utilizing  the  same 
central  building.  Each  wing  or  ward  will  accommodate  160  patients, 
giving  a  total  capacity  of  640  for  the  finally  completed  institution. 
The  first  story  of  the  entire  structure  is  of  sandstone  found  on  the 

(341) 


98  The  Annals  of  the  American  Academy 

property.  The  second  story  is  of  asbestos  boards  timbered,  and  the 
roof  will  be  of  asbestos  shingles.  The  layout  permits  of  the  maxi- 
mum amount  of  sunlight,  with  the  wards  so  arranged  as  to  accom- 
modate the  varying  demand  of  advanced  and  incipient  cases.  The 
central  building  will  provide  a  dining  room,  reception  and  exam- 
ining room  on  the  first  floor  and  apartments  for  the  doctors,  nurses 
and  help  on  the  second  floor. 

Connecting  the  east  and  west  wards  with  the  central  building 
are  corridors  that  have  enclosed  basements  through  which  the 
patients  can  walk  to  the  dining  room  in  stormy  weather,  and  a 
first  floor  to  be  used  for  the  open-air  treatment.  Here  the  patients 
may  sit  in  their  rest-chairs  and  enjoy  the  sunshine,  and  thus  is 
overcome  the  necessity  of  porches  that  would  block  out  the  sun 
from  the  patients'  rooms.  Into  this  sun-corridor  also  the  patient's 
bed  can  be  wheeled.  To  economize  by  using  the  same  foundation 
and  roof  for  as  much  as  possible,  a  second  floor  of  each  connecting 
corridor  will  accommodate  twenty  beds  for  hospital  cases. 

The  sanatorium  site,  about  2,400  feet  above  the  sea  level,  is 
sufficiently  far  from  all  industries  to  have  pure  air  for  the  patients 
to  breathe.  The  summers  are  cool  and  the  winters  long  and  un- 
broken. 

At  Hamburg,  in  lierks  county,  a  site  has  been  purchased  for 
an  eastern  sanatorium,  which  will  be  built  along  the  same  lines  as 
the  one  at  Cresson.  The  site  selected  commands  a  pleasing  view  of 
wooded  mountains,  broken  into  gaps  and  peaks,  with  the  Schuylkill 
River  winding  in  the  valley  to  the  west.  Far  enough  away  to  avoid 
all  objection  of  noise  and  smoke,  but  near  enough  to  relieve  a  sense 
of  lonesomeness,  the  Schuylkill  Valley  branches  of  the  Pennsylvania 
and  Reading  railroads  are  seen.  The  quaint  town  of  Hamburg 
nestles  in  the  valley  below,  bordered  by  fertile  stretches  of  farm 
lands  with  their  restful,  pastoral  scenes. 

At  these  three  state  institutions,  Mont  Alto,  Cresson  and  Ham- 
burg, the  poor  will  receive  ideal  treatment  for  tuberculosis.  They 
will  not  suffer  under  the  disadvantages  of  city  hospitals,  where  their 
lungs  would  be  constantly  irritated  by  the  smoke  and  dust  so  common 
to  all  large  municipalities. 

Hand  in  hand  with  the  sanatorium  work  goes  the  dispensary 
treatment.  At  one  hundred  and  fifteen  places  in  Pennsylvania 
the  State  Department  of  Health  has  a  free  tuberculosis  dispensary 

(342) 


Protecting  Public  Health  in  Pennsylvania  99 

in  charge  of  a  trained  physician,  with  necessary  assistants  and  visit- 
ing nurses.  Some  idea  of  the  amount  of  work  being  done  by  these 
dispensaries  may  be  gathered  from  the  fact  that  up  to  November 
30,  19 10,  38,289  patients  had  registered  for  examination  and  treat- 
ment. 

I  beHeve  that  the  educational  and  sociological  work  alone  that 
is  being  done  by  the  state  from  these  dispensaries,  to  prevent  the 
spread  of  disease  and  to  better  the  conditions  of  living  among  the 
poor,  would  amply  justify  all  the  money  Pennsylvania  has  appro- 
priated for  its  tuberculosis  campaign. 

When  these  dispensaries  were  first  started  we  realized  that 
if  they  were  to  be  fully  successful,  we  should  first  of  all  have  to 
reach  the  indigent  cases.  We  therefore  solicited  and  received  the 
hearty  co-operation  of  civic  clubs,  churches,  organized  charity  organ- 
izations, labor  unions  and  the  large  employers  of  labor  throughout 
the  state.  This  co-operation  has  always  continued,  and  the  depart- 
ment appreciates  its  value. 

When  an  applicant  for  dispensary  treatment  has  been  carefully 
examined  by  the  physician  in  charge,  and  full  information  as  to  the 
history  of  the  case,  environment,  occupation,  etc.,  noted,  he  is  care- 
fully instructed  as  to  what  he  must  do  to  improve  his  own  health 
and  the  absolute  necessity  of  taking  certain  precautions  to  avoid 
infecting  others.  He  is  supplied  with  sputum  cups  and  paper  nap- 
kins, and  if  too  poor  to  get  regularly  the  proper  nourishment,  this 
is  supplied  to  him  either  in  the  form  of  milk  and  eggs  or  milk  and 
oil,  the  latter  having  proven  a  most  efficient  food. 

A  day  or  so  after  the  new  patient  has  been  to  the  dispensary 
a  trained  nurse  calls  at  the  home.  The  squalor  and  disease-breeding 
conditions  that  the  nurse  so  frequently  finds  present  a  task  that 
would  seem  impossible.  But  the  nurse  is  all  courage.  Bright 
and  cheerful  and  a  model  of  cleanliness  herself,  she  is  not  afraid 
to  roll  up  her  sleeves  and  set  the  pace  for  getting  the  house  in  order. 
Windows  are  thrown  open,  and  God's  glorious  sunshine  is  allowed 
to  come  in  and  run  riot  through  the  rooms,  killing,  as  nothing 
else  can  do  so  well,  the  lurking  germs  of  disease.  What  a  diflference 
is  made  in  that  home ! 

The  tuberculosis  patient  is  again  thoroughly  instructed  in  the 
precautions  he  must  observe  and  the  health  rules  he  must  follow, 
and  each  member  of  the  family  is  similarly  taught  how  to  avoid 

(343) 


ICXD  The  Annals  of  the  American  Academy 

infection.  The  patient  himself  is  especially  advised  to  sleep  with 
windows  wide  open,  or,  better  still,  to  sleep  out  of  doors.  Helpful 
suggestions  are  offered  as  to  how  sleeping  quarters  can  be  made  out 
of  back  porches,  for  instance,  at  a  nominal  expense.  Then  the 
nurse  makes  a  quick  study  of  the  other  conditions  in  the  home. 
Perhaps  she  notices  that  the  children  are  anemic,  poorly  nourished 
and  improperly  clad,  not  necessarily  because  the  family  is  desti- 
tute, but  because  the  little  income  that  exists  is  not  being  put  to 
best  advantage.  Here  is  an  opportunity  to  teach  the  mother  how 
both  in  selecting  and  cooking  the  food  the  greatest  possible  nutrition 
can  be  secured  for  the  least  amount  of  money. 

So  it  is  that  our  nurses  are  going  to  the  homes  of  the  poor 
throughout  Pennsylvania,  letting  in  the  sunlight,  teaching  the  life- 
giving  principles  of  fresh  air  and  proper  food,  changing  filth  and 
disorder  to  cleanliness  and  neatness,  making  these  people  their 
friends,  and  thus  making  them  understand  that  the  state  is  their 
friend.  Can  there  possibly  be  any  other  result  than  that  these  people 
should  be  lifted  up,  or,  better  still,  that  they  should  be  incited  to 
climb  up  to  a  higher  plane  of  living  and  morality?  Thus  they 
become  better  citizens,  better  producers,  and  the  commonwealth 
is  so  much  the  healthier,  wealthier  and  happier  thereby.  Do  you 
wonder  why  I  say  this  work  alone  is  worth  all  the  money  that  Penn- 
sylvania is  spending  to  fight  tuberculosis  ? 

In  sixty-six  counties  of  the  state  the  department  has  a  thor- 
oughly trained  medical  inspector,  assisted  by  a  corps  of  township 
health  officers.  There  are  altogether  seven  hundred  of  the  health 
officers  distributed  throughout  the  state.  To  them  the  physicians 
report  all  cases  of  communicable  diseases,  and  the  health  officers 
promptly  placard  the  premises  and  establish  the  necessary  quar- 
antine. Upon  receiving  notice  from  the  physicians  of  the  termina- 
tion of  the  case,  the  health  officer  thoroughly  disinfects  the  premises. 
As  a  proof  of  the  results  being  obtained  from  educational  work,  it 
has  been  gratifying  to  note  the  constantly  increased  number  of 
requests  from  householders  to  have  their  houses  disinfected  after 
cases  of  tuberculosis.  The  tuberculosis  and  general  sanitary 
exhibit  that  the  department  has  been  sending  through  the  state 
has  been  a  big  factor  in  teaching  the  people  to  keep  themselves 
healthy.      Especially   fruitful   have   been   the   talks    to   the    school 

(344) 


Protecting  Public  Health  in  P'ehiUyivdfiia'>''  '^''^''€01 

children,  who  have  not  only  learned  .the  lessons  themselves,  but 
carried  the  message  of  health  to  their  homes. 

In  connection  with  this  work  of  educating  the  people,  I  want 
to  take  this  opportunity  of  referring  to  the  splendid  aid  given  us 
by  the  public  press  in  general.  Through  it,  we  have  been  able  from 
day  to  day  and  week  to  week  to  talk  over  these  problems  of  better 
health  and  better  living  conditions  with  the  home  group  around 
every  fireside  in  the  state. 

The  new  sanitary  code  passed  by  the  last  legislature  has  already 
been  productive  of  far  more  efficient  health  work  in  munici- 
palities throughout  Pennsylvania  by  establishing  uniformity  in  the 
rules  for  the  control  of  communicable  diseases.  The  State  Depart- 
ment of  Health  through  its  organized  army  of  medical  inspectors 
and  health  officers  has  kept  guard  against  the  spread  of  disease  in 
the  rural  districts,  and  whenever  necessary  has  aided  local  boards 
of  health  in  battling  with  epidemics  that  threatened  to  get  beyond 
control.  By  example  and  by  helpful  advice  and  instruction  these 
local  boards  have  been  greatly  benefited,  and  in  many  municipali- 
ties, where  no  sanitary  precautions  were  being  observed,  boards  of 
health  have  been  organized  and  stimulated  to  do  effective  work  for 
their  respective  communities. 

The  inspection  of  dairy  farms  by  the  department's  health  offi- 
cers as  a  protection  to  the  milk  supply  is  a  most  necessary  part  of 
the  state's  sanitary  work,  and  will  be  carried  on  with  a  thorough- 
ness which  only  a  well-organized  and  adequate  force  of  inspectors 
can  attain. 

These  health  officers  also  for  the  past  two  years  have  been 
making  regular  inspections  of  the  sanitary  conditions  of  all  schools 
in  the  rural  districts,  and  the  result  has  been  a  very  marked  im- 
provement at  such  schools.  The  department  has  also  started  a 
system  of  medical  inspection  of  the  school  children  in  the  rural 
districts.  This  inspection  is  being  made  by  skilled  physicians.  In 
view  of  the  results  already  accomplished  by  medical  inspection  of 
schools  in  some  of  the  larger  cities  and  municipalities  throughout 
the  country,  we  are  safe  in  saying  that  the  standard  of  health  of 
the  children  in  the  country  schools  in  Pennsylvania  will  be  raised 
materially  by  this  work. 

When,  in  1905,  a  state  law  was  passed  to  protect  the  waters 
of  the  state  from  pollution  it  seemed  as  if  an  almost  hopeless  task 

(345) 


102  ' '   '  '  ■  '  'The  'Amials  of  the  American  Academy 

was  being  undertaken.  If  the  truth  must  be  confessed  there  was 
nowhere  a  more  flagrant  example  than  Pennsylvania  of  the  criminal 
poisoning  of  the  people's  drinking  water  by  disease-laden  sewage. 
Private  individuals,  corporations  and  municipalities,  large  and  small, 
were  equally  guilty.  All  this  has  not  yet  been  changed.  That  would 
be  inconceivable.  But  almost  unhoped-for  progress  has  been  made, 
and  this  because  the  law  has  been  administered  wisely  and  justly, 
and  the  people  themselves  have  been  taught  to  understand  and  ap- 
preciate the  absolute  necessity  and  the  real  economy  of  protecting 
their  water  supplies  from  pollution.  Twenty-six  thousand  four  hun- 
dred and  sixty-six  private  sources  of  stream  pollution  have  been 
abated  by  the  department  to  date.  Seventy-six  modern  sewage  dis- 
posal plants  have  been  either  built  or  are  in  progress  of  construc- 
tion, as  approved  by  the  state.  Two  hundred  and  forty-six  other 
municipalities  and  private  sewerage  corporations  are  preparing  plans 
to  be  submitted  to  the  department  that  embrace  sewage  treat- 
ment as  a  condition  upon  which  the  further  extension  of  their  sew- 
erage systems  is  granted.  Seventy-nine  modern  water  filtration 
plants  have  been  approved  by  the  state  and  are  either  already  in 
operation  or  under  construction. 

Thousands  of  physicians  throughout  Pennsylvania  are  being 
constantly  aided  in  diagnosing  their  cases  by  the  examinations  of 
pathological  specimens  sent  by  them  to  the  State  Department  of 
Health  laboratories.  Important  research  work  is  being  done  by 
the  state  in  these  laboratories,  work  that  is  adding  to  the  world's 
knowledge  of  preventive  medicine. 

More  than  once  in  the  past  four  years  the  federal  government 
has  held  up  as  a  model,  Pennsylvania's  system  for  the  collection  of 
vital  statistics,  that  phase  of  work  that  lies  at  the  foundation  of  all 
successful  sanitation. 

Viewed,  therefore,  from  every  line  of  activity  that  it  touches, 
the  State  Department  of  Health,  I  hope,  commends  itself  to  the 
loyal  support  of  the  people.  Far  reaching  as  the  work  has  been  it 
must  go  forward  with  increasing  vigor.  The  people's  battle  for 
health  must  be  won.    And  it  will  be  won. 


(346) 


HEALTH  PROBLEMS  OF  THE  INDIANS 


By  Joseph  A.  Murphy,  M.D,, 
Medical  Supervisor,  United  States  Indian  Service. 


The  various  phases  of  the  health  problem  among  Indians,  in- 
volve also  the  many  varied  conditions  which  constitute  what  is 
known  as  the  Indian  Problem  as  a  whole,  which  has  been  so  long 
before  the  American  nation.  It  seems  only  to  have  been  within 
recent  years  that  the  importance  of  considering  the  necessity  for 
action  looking  toward  the  improvement  of  the  health  conditions 
among  them  has  been  realized.  Sentiment  ranging  from  the  often 
expressed  opinion  that  the  only  good  Indian  is  a  dead  one,  to  the 
other  extreme,  has  and  should  be  changed  to  the  saner  realization 
that  the  conditions  resulting  in  the  Indian  dead  or  diseased  on 
account  of  contagious  infections,  are  not  only  a  menace  to  the  race 
itself,  but  also  to  the  health  of  the  people  of  the  states  in  which 
they  live. 

General  statistics  in  regard  to  the  prevalence  of  disease  among 
Indians  are  either  incomplete  and  far  from  accurate,  or  have  not 
been  compiled.  General  vital  statistics  are  also  inaccurate.  It  is 
only  in  those  places  where  allotments  are  actually  being  assigned  * 
that  statistics  in  regard  to  the  population,  births  and  deaths  are 
reliable.  The  Navajo  Indians,  for  instance,  are  scattered  over  a 
wide  range  or  desert.  Their  births  and  deaths  cannot  be  accurately 
obtained.  Many  other  Indian  children  among  the  less  advanced 
tribes  are  born  and  die  far  away  from  any  physician  or  government 
employee. 

Where  there  is  lack  of  co-operation  on  the  part  of  the  Indian 
it  can  be  readily  seen  that  the  occurrence  of  births  or  deaths  and  the 
causes  of  the  latter  will  remain  unknown.  Physicians  are  not  sum- 
moned to  the  great  majority  of  cases,  and  even  yet  the  medicine 
men  in  some  tribes  have  a  hold  on  the  beliefs  of  the  people  and  are 
given  charge  instead.  With  such  chances  for  error  in  the  general 
statistics,  it  is  only  where  a  special  comprehensive  investigation  has 
been  made  that  the  real  conditions  can  be  determined.     There  is 

(347) 


I04  The  Annals  of  the  American  Academy 

then,  primarily,  a  great  need  for  investigation  and  study  of  the  pre- 
valence of  disease  among  Indians,  and  need  for  more  accurate  regis- 
tration of  vital  statistics,  and  for  the  registration  of  contagious  and 
infectious  diseases.  It  will  only  be  through  the  knowledge  gained 
in  this  way  that  conditions  will  be  fully  realized  and  intelligent 
action  can  be  taken  for  their  improvement. 

The  work  of  the  Indian  service  physicians  in  the  past  has  not 
been  specifically  directed  toward  the  prevention  of  disease,  but  since 
special  studies  have  shown  that  the  morbidity  and  mortality  from 
infectious  disease  is  excessively  high  among  Indians,  it  is  evidently 
imperative  that  they  must  not  only  treat  the  ills  which  actually 
present  themselves,  but  make  persistent,  systematic,  rigid  examina- 
tions and  frequent  thorough  inspections  of  all  the  Indians  under 
their  charge  for  the  purpose  of  detecting  cases  of  contagious  dis- 
eases, submitting  them  to  treatment  and  checking  them  in  the  incip- 
ient stages,  and  in  addition,  correcting  insanitary  customs  and  con- 
ditions which  are  responsible.  Invasion  of  the  Indian  home  for  the 
purpose  of  examination  of  unwilling  or  reluctant  adults  or  children 
is  a  work  that  is  not  only  frequently  resented  as  unwarranted  inter- 
ference, but  also  frequently  prevented.  The  gratuitous  advice  for 
the  remedying  of  ailments,  offered  treatment  of  disease,  and  sug- 
gestions for  the  improvement  of  sanitary  conditions  in  the  homes 
are  frequently  either  disregarded  or  refused.  Treatment  appar- 
ently accepted  is  seldom  persisted  in  except  among  the  most  ad- 
vanced tribes,  and  among  these  the  practice  of  medicine  is  very 
similar  to  that  among  whites.  This  attitude  on  the  part  of  the 
Indians,  which  is  not  unwarranted  nor  unreasonable,  and  one  which 
would  be  assumed  by  white  people  imder  similar  conditions,  has 
greatly  hindered  the  attempt  to  improve  sanitary  conditions,  and  in 
some  localities  has  rendered  even  special  investigations  or  special 
treatment  incomplete  and  unsatisfactory. 

According  to  the  most  accurate  returns  available  the  general 
birth  rate  among  Indians  for  the  fiscal  year  19 lo  was  30.2  per 
thousand;  the  death  rate  24.0  per  thousand,  40.1  per  cent  of  which 
was  due  to  tuberculosis.  The  death  rate  per  thousand  due  to  tuber- 
culosis was  10.4.  These  figures  are  .probably  more  nearly  correct 
than  those  of  1909,  which  are: 

Birth  rate  per  thousand,  30.6. 

(348) 


Health  Problems  of  the  Indians  105 

Death  rate  per  thousand,  25.54. 

Percentage  of  deaths  due  to  tuberculosis,  30.25. 

Death  rate  per  thousand  due  to  tuberculosis,  7.71. 

If  these  figures  were  accurate  they  would  indicate  a  great 
increase  in  mortality  from  tuberculosis  during  the  year  1910,  but  this 
increase  is  apparent  rather  than  real  and  is  due  to  error  in  the  re- 
turn. Comparing  the  mortality  among  Indians  with  that  of  whites, 
the  returns  from  the  registration  area  of  the  United  States  for 
1909  show  a  death  rate  of  15.0  per  thousand  of  the  population,  11. 2 
per  cent  of  which  was  due  to  tuberculosis.  The  total  mortality 
among  Indians  then  is  60  per  cent  higher  than  that  among  whites, 
and  the  percentage  due  to  tuberculosis  258  per  cent  higher,  or  over 
three  times  as  great  as  the  average  mortality  from  the  same  cause 
among  whites. 

In  addition  to  the  great  morbidity  and  mortality  from  tubercu- 
losis, the  Indians  suffer  to  a  very  great  extent  from  other  conta- 
gious and  infectious  diseases  as  well  as  the  parasitic  infestations. 
One  of  the  most  common  serious  diseases  is  trachoma.  Of  22,340 
Indians  examined  during  the  year  1910,  6,124  cases  of  trachoma 
were  found,  a  percentage  of  infection  of  27.4  per  cent.  This  dis- 
ease exists  in  both  the  North  and  South,  but  seems  more  prevalent 
among  the  southern  tribes. 

Pneumonia  is  a  very  common  disease,  though  not  apparently 
more  or  less  prevalent  than  among  whites.  Impetigo  contagiosa  is 
exceedingly  common.  It  frequently  complicates  scabies,  which  is 
almost  constant  in  many  camps.  The  great  frequency  of  suppura- 
tive tubercular  glands  and  impetigo  has  given  rise  to  a  popular 
opinion  that  these  ulcers  are  an  indication  of  syphilis.  While  vene- 
real diseases  are  present  among  certain  tribes,  they  are  probably 
not  present  in  as  large  a  proportion  among  a  majority  of  the  In- 
dian tribes  as  they  are  among  whites. 

Measles  is  a  very  serious  disease  because  of  the  large  per- 
centage of  tubercular  infection.  As  a  sequel  actively  progressive 
tuberculosis  frequently  results  in  a  rapid  fatal  termination.  The 
same  is  true  of  pertussis.  Digestive  disturbances,  due  to  the  condi- 
tion and  quality  of  the  food  eaten,  is  not  only  responsible  for  a  large 
mortality  among  Indian  children  and  infants,  but  for  great  general 
morbidity  at  all  ages.     Scarlet  fever  and  diphtheria  are  present  to 

(349) 


io6  The  Annals  of  the  American  Academy 

about  the  same  extent  as  among  whites.    Typhoid  is  not  as  preva- 
lent as  among  those  who  Hve  in  more  congested  communities. 

The  most  prevalent  diseases  to  be  considered  are  tuberculosis, 
trachoma,  nutritional  disorders  and  parasitic  infestations.  It  is  the 
condition  of  the  Indian  homes,  their  habits,  customs  of  living  and 
ignorance  of  sanitary  requirements  that  are  primarily  at  fault.  In 
the  North  during  the  cold  season  individual  families  of  a  large  num- 
ber of  the  tribes  live  crowded  together  at  night  in  one  unventilated 
room.  Tubercular  cases  spit  on  the  floors  and  no  attempt  is  made 
to  prevent  the  entire  home  and  its  surroundings  from  becoming 
badly  infected.  The  Indians  eat  from  these  infected  floors,  flies 
swarm  on  the  food,  and  in  the  sputum.  Blankets  used  as  pallets  on 
the  floors  become  badly  infected  and  extremely  dirty.  Excreta  and 
household  refuse  are  inadequately  disposed  of.  Children  brought  up 
in  such  environments  are  necessarily  constantly  subjected  to  tuber- 
cular and  other  infection,  and  it  is  only  the  fact  that  the  greater  part 
of  the  day  is  spent  in  the  open  air  that  prevents  a  rapid  advance  and 
more  frequent  fatal  termination  of  the  diseases  contracted.  Poor, 
insufficient,  badly  prepared  and  improperly  kept  food  of  insufficient 
variety  frequently  adds  to  the  factors  which  contribute  to  the  break- 
ing down  of  the  resistance  of  the  infected  Indians.  Infected  food 
is  also  a  frequent  method  of  spread  of  disease.  In  the  South  the 
crowding  conditions  are  largely  the  same.  The  conditions  of  filth, 
lack  of  ventilation  and  light  (many  houses  being  windowless),  in- 
fected earth  floors,  absence  of  the  attempt  to  segregate  contagious 
cases  or  .prevent  in  any  way  the  spread  of  disease,  results  in  the 
same  high  percentage  of  .infection.  Some  tribes  are  exceptions  to 
this  general  description,  there  being  all  gradations  from  those  who 
live  under  practically  tfie  same  conditions  as  the  average  white 
family,  to  those  of  extreme  filth  and  insanitary  environment  and 
habits.  Whole  families  become  infected  with  trachoma  from  the 
intimate  contact  of  the  crowded  home.  Lack  of  attempt  to  obtain 
medical  treatment  finally  results  in  permanent  impairment  of  vision 
or  even  complete  destruction  of  sight.  Since  cases  of  this  sort  are 
present  in  large  numbers  scattered  widely  all  over  the  various  res- 
ervations, it  is  not  hard  to  conceive  what  a  difficult  task  the  service 
physician  has  to  search  out  these  cases  and  give  adequate  treatment, 
especially  where  they  are  not  inclined  to  accept  or  appreciate  it. 

(350) 


Health  Problems  of  the  Indians  107 

It  is  extremely  important,  however,  that  this  work  be  attempted 
for  the  protection  of  the  tribe  as  a  whole. 

It  has  been  a  matter  of  observation  for  many  years  that  a 
certain  proportion  of  the  pupils  at  non-reservation  and  reservation 
boarding  schools  developed  pulmonary  tuberculosis  and  had  to  be 
returned  to  their  homes.  Sanitary  conditions,  cleanliness  and  nu- 
trition were  far  better  at  these  institutions  than  at  the  Indian  homes, 
and  it  seemed  that  there  must  be  some  vital  defect  in  the  school 
methods.  While  there  may  have  been  sanitary  defects  in  the  school 
system  contributing  to  this  high  morbidity,  it  is  at  present  well 
recognized  that  many  children  come  to  the  school  with  latent  or 
partially  arrested  tubercular  infection.  The  majority  are  vastly 
benefited  by  the  improved  nutrition  and  sanitary  conditions,  but  the 
confinement  of  school  life  and  strain,  tension  and  fatigue  induced  by 
the  requirements  of  rigid  routine  are  enough  to  account  for  a  suffi- 
cient breaking  down  of  resistance  of  some  to  allow  the  extension  of 
latent  infection.  An  epidemic  of  measles  passing  through  the 
school  leaves  the  same  fatal  wake  of  cases.  These  facts  have  not 
been  so  well  understood  in  the  past,  nor  has  the  necessity  been  real- 
ized for  a  constant  vigilance  on  the  part  of  the  physicians  and 
school  authorities  to  detect  in  its  earliest  manifestations  any  symp- 
toms of  .pulmonary  disease.  Failure  to  do  this  has  resulted  fre- 
quently in  a  certain  proportion  of  contagion  and  spread  in  the 
schools. 

The  solution  of  the  problem  of  improving  health  conditions  is 
being  met  along  a  number  of  separate  lines.  Systematic  field  in- 
spections are  being  made  by  the  medical  supervisor  and  his  field 
assistants.  Local  physicians  are  directed  to  systematize  their  medi- 
cal inspections  of  the  schools  and  reservation  Indians  with  such 
thoroughness  as  to  detect  and  place  under  treatment  incipient  dis- 
ease. A  new  system  of  records  for  the  recording  and  reporting  of 
medical  cases  and  the  registration  of  infectious  diseases,  including 
tuberculosis  and  trachoma,  has  been  introduced.  This  should  in- 
sure more  complete  and  more  accurate  statistics,  and  will  indicate 
more  precisely  the  need  for  work  in  special  localities.  As  a  result 
of  more  frequent  and  general  medical  inspection  of  schools  and 
reservations,  sanitary  measures  will  be  better  enforced  and  local 
necessary  reforms  instituted. 

(351) 


io8  The  Annals  of  the  American  Academy 

It  will  only  be  through  education  that  any  real  lasting  results 
may  be  accomplished.  The  subject  of  tuberculosis  is  being  studied 
from  special  text  books  by  every  pupil  capable  of  understanding  it,, 
and  additional  improved  modern  books  on  hygiene  have  been  placed 
in  the  school  curriculum.  Circulating  sets  of  stereopticon  slides, 
illustrating  the  method  of  spread  of  tuberculosis  in  Indian  homes, 
and  methods  of  its  prevention  and  cure  are  being  distributed  to  all 
the  schools  and  agencies.  A  lecture  illustrated  by  moving  pictures 
showing  the  important  phases  of  insanitary  Indian  customs,  habits 
and  conditions,  and  the  methods  of  preventing  the  spread  of  the 
diseases  common  among  Indians,  is  being  sent  to  all  schools  and 
agencies  throughout  the  country.  Literature  in  regard  to  the  cause, 
prevention  and  cure  of  tuberculosis  will  be  distributed  on  the  re- 
servations among  all  Indians  who  can  read.  To  eflfect  radical 
changes,  raising  the  standard  of  living  among  the  older  Indians,  is 
a  difficult  undertaking,  but  the  emphasis  that  is  being  placed  on  the 
subject  of  health  and  sanitation  in  the  schools  is  bound  to  bring 
good  results  with  the  younger  generation. 

For  the  improvement  of  home  conditions  the  field  matrons  have 
been  placed  under  the  direction  of  the  Health  Section  of  the  Indian 
Office,  and  a  special  field  supervisor  placed  in  charge.  For  the  pur- 
pose of  increasing  the  efficiency  of  the  field  matron  force  in  improv- 
ing sanitary  conditions  in  the  homes,  printed  instructions  will  be 
furnished  to  all  field  employees  directing  and  instructing  them  in 
the  methods  of  correcting  these  conditions.  The  education  of  the 
government  employees  in  direct  contact  with  the  Indians  is  as  im- 
portant a  matter  as  the  education  of  the  Indians  themselves,  for  the 
employees'  influence  cannot  and  will  not  be  exerted  along  the  de- 
sired lines  unless  the  employees  are  properly  directed.  It  will  re- 
quire considerable  detailed  instruction  to  make  efficient  sanitarians 
of  employees  who  are  not  trained  or  specially  educated  for  the 
work,  but  their  assistance  must  be  depended  upon  to  help  out  the 
work  of  the  physician. 

The  treatment  of  the  diseased  Indians  is  also  a  serious  under- 
taking. In  the  schools,  monthly  weighing  of  pupils  and  regular 
physical  examinations  by  che  physicians  is  intended  to  sift  out  those 
who  are  infected  or  predisposed  to  disease.  Screened  porches  at- 
tached to  hospitals  and  dormitories  are  to  be  built  for  the  open-air 

(352) 


Health  Problems  of  the  Indians  109 

treatment  of  such  pupils  as  show  pulmonary  weakness.  These 
porches  have  already  been  built  in  many  places.  If  cases  of  pul- 
monary tuberculosis  develop  at  the  boarding-  schools,  either  they 
must  be  sent  to  their  homes  or  to  special  sanatoria.  These  sanatoria 
are  being  started  in  various  sections  of  the  country. 

Advanced  cases  of  tuberculosis  in  the  home  are  undoubtedly 
the  nuclei  for  the  spread  of  infection  to  many  additional  cases,  and 
the  problem  of  preventing  this  is  a  difficult  one.  Local  camps  could 
be  used  to  care  for  these  cases,  but  the  Indians  are  frequently  un- 
willing to  submit  to  treatment.  These  camps  are  being  established, 
but  force  cannot  be  used  to  compel  attendance.  Even  the  white 
race  is  not  willing  to  submit  to  coercive  measures  of  this  character. 

In  addition  to  the  special  measures  directed  against  tubercu- 
losis, a  campaign  is  in  progress  for  the  treatment  of  trachoma. 
Special  expert  physicians  and  nurses  are  being  sent  to  all  infected 
regions  to  operate  upon  the  cases  and  instruct  the  local  physicians 
how  to  treat  the  disease.  As  soon  as  this  work  is  accomplished 
satisfactorily  at  one  school  or  agency,  it  is  left  to  the  local  physician 
and  other  territory  visited.  A  special  hospital  for  the  treatment  of 
trachoma  was  established  at  Phoenix,  and  service  physicians  nearby 
are  being  detailed  for  periods  of  one  month  each  to  assist  at  the 
hospital  and  receive  clinical  instruction  from  the  specialist  in  charge. 
This  general  plan  of  work  has  been  successful  and  has  already 
resulted  in  a  solution  of  the  problem  in  many  localities. 

As  allotments  are  rapidly  being  assigned,  reservations  opened 
up  to  settlement  and  the  Indians  becoming  citizens  of  the  state,  the 
continuation  of  the  work  of  improving  the  above  outlined  condi- 
tions will  become  a  problem  to  be  assumed  by  the  state  authorities 
instead  of  by  the  National  Government. 


(353) 


HEALTH  PROBLEMS  OF  THE  NEGROES 


By  John  A.  Kenney,  M.D., 
Tuskegee  Institute,  Ala. 


It  is  gratifying  to  state  that  the  Negroes  are  becoming  very 
active  in  the  crusade  against  preventable  diseases.  In  many  places, 
without  quibbling  over  such  academic  questions  as  whether  the 
Negro  is  dying  as  rapidly  as  some  other  people,  or  whether  there 
is  some  racial  inherency  productive  of  its  high  mortality,  or  whether 
it  is  due  to  environment,  the  race  is  realizing  that  its  death  rate 
is  high;  that  certain  diseases  are  taking  more  than  their  fair  toll 
of  human  life  from  its  ranks,  and  that  many  of  these  diseases 
are  preventable.  With  this  realization,  many  Negroes  have  set  to 
work  to  improve  their  living  conditions  and  reduce  mortality. 

As  might  be  expected,  the  medical  profession  was  among  the 
first  to  realize  this  and  to  seek  for  improvement.  In  the  year  1895 
the  National  Medical  Association,  composed  of  representative 
Negroes  in  the  practice  of  medicine,  dentistry  and  pharmacy,  was 
organized  in  the  city  of  Atlanta,  with  the  object  of  improving  the 
conditions  of  Negro  professional  men,  and  through  them,  helping 
to  educate  the  masses  along  the  line  of  better  health  and  right 
living.  The  influence  of  this  organization  has  been  felt  in  most  of 
the  country  east  of  the  Mississippi  river,  from  Boston  in  the  North. 
to  Atlanta  in  the  South.  At  its  annual  sessions,  one  of  the  chief 
features  has  been  at  least  one  public  session,  for  the  benefit  of  the 
people,  when  subjects  of  popular  interest  are  discussed  in  simple 
language.  Among  the  topics  thus  presented  are  the  following: 
The  Cause,  Prevention,  and  Treatment  of  Tuberculosis;  Infant 
Mortality ;  The  Proper  Care  and  Feeding  of  Infants,  etc. 

That  these  discussions  have  been  appreciated  by  the  laity  is 
attested  by  the  fact  that  they  have  always  been  given  in  crowded 
halls,  and  we  have  every  reason  to  believe  that  they  have  done  good. 

Before  the  organization  of  the  National  Medical  Association, 
there  were  in  existence  few  state  and  local  medical  societies  among 

(354) 


Health  Problems  of  the  Negroes  in 

the  Negroes.  Most  of  those  that  were  in  existence  have  affiliated 
with  the  National,  and  a  great  many  others  have  been  organized 
under  its  influence.  At  the  present  time,  nearly  every  state  having 
a  sufficient  number  of  Negro  physicians  has  its  medical  society,  and, 
aside  from  this,  nearly  all  the  cities  and  many  of  the  large  towns 
also  have  local  societies ;  and  almost  without  exception,  to  a  variable 
degree,  they  are  striving  to  help  the  Negro  people  attain  to  higher 
planes  of  living,  and  thus  improve  their  health  and  reduce  their 
death  rate. 

Early  in  the  year  1910,  the  executive  board  of  the  National 
Medical  Association  appointed  a  commission  to  study  tuberculosis, 
hookworm  disease,  and  pellagra  among  the  Negroes.  These  reports, 
though  incomplete,  furnished  one  of  the  interesting  features  of  the 
last  meeting  of  the  association. 

A  few  illustrations  may  be  mentioned.  In  1908  the  Bay  State 
Medical  Society  of  Boston,  Mass.,  began  a  series  of  public  meet- 
ings. The  first  meeting  was  held  Sunday,  February  3,  the  general 
subject  of  "Hygiene"  being  discussed  under  the  following  heads : 
"Oral  Hygiene,"  Personal  Hygiene,"  and  "Practical  Hygiene."  In 
March,  the  general  subject  of  "Water''  was  discussed  as  follows: 
"Contamination  of  Water,"  "Purification  of  Water,"  "Medicinal 
Uses  of  Water,"  In  April,  "Milk"  was  the  general  subject,  and 
was  discussed  as  follows  ^  "Human  Milk  and  Its  Advantages,"  "Con- 
tamination of  Milk,"  "Infant  Feeding."  In  Alay  the  general  sub- 
ject of  "Tuberculosis"  was  discussed  as  follows:  First,  "Past, 
Present  and  Future  of  Tuberculosis ;"  second,  "Channels  of  Infec- 
tion, and  Early  Symptoms;"  third,  "Efforts  Being  Made  to  Control 
the  Disease." 

These  meetings  were  all  well  attended,  and  evinced  a  surpris- 
ing amount  of  interest  on  the  part  of  the  people  in  all  walks  of  life. 
Since  that  season  the  society  has  held  many  similar  meetings  in 
all  the  colored  churches  of  the  city.  Similar  meetings  have  been 
held  by  the  North  Jersey  Medical  Society.  It  is  the  policy  of  this 
society  to  hold  four  of  these  meetings  each  year. 

At  the  last  meeting  of  the  Louisiana  Medical,  Dental  and 
Pharmaceutical  Association,  one  hundred  dollars  was  appropriated 
by  the  society  as  a  nucleus  for  the  establishment  of  a  tuberculosis 
hospital  for  the  treatment  of  Negro  patients.  A  committee  has 
been  appointed  to  formulate  plans  and  secure  a  location.    An  Anti- 

(355) 


112  The  Annals  of  the  American  Academy 

Tuberculosis  League  has  been  established  by  Negro  physicians  of 
Louisiana.  Lectures  on  hygiene,  sanitation,  and  tuberculosis  are 
delivered  by  Negro  physicians  to  schools,  associations,  and  summer 
normals.  A  public  health  car  has  been  put  into  service  by  the 
Louisiana  State  Board  of  Health,  which  is  admirably  equipped,  for 
the  purpose  of  traveling  through  the  state,  stopping  at  various 
towns  and  cities,  where  lectures  are  delivered  on  hygiene  and  sani- 
tation. 

The  Alabama  Medical,  Dental  and  Pharmaceutical  Associa- 
tion has  for  a  number  of  years  devoted  especial  attention  to  topics 
pertaining  to  the  health  and  sanitary  conditions  of  the  people.  At 
its  meeting  in  Selma,  in  1909,  one  evening  session  was  devoted 
to  the  subject  of  tuberculosis,  in  one  of  the  largest  churches  in 
the  city,  which  was  packed  with  an  interested  and  appreciative 
audience. 

The  Lone  Star  Medical,  Dental  and  Pharmaceutical  Associa- 
tion of  Texas  holds  annual  meetings,  and,  aside  from  the  purely 
professional  aspects  of  these  gatherings,  especial  attention  is  paid 
to  health  topics. 

The  Medico-Chirurgical  Society  of  New  York,  for  the  past 
year  has  been  teaching  the  people  by  means  of  lectures  in  the  dif- 
ferent churches,  etc. 

The  Medico-Chirurgical  Society  of  the  District  of  Columbia, 
with  a  membership  of  seventy  or  eighty,  devotes  much  of  its  atten- 
tion to  topics  pertaining  to  the  public  health.  An  anti-tuberculosis 
league  has  been  formed  in  the  city  of  Washington,  with  a  member- 
ship of  about  2,000. 

In  addition  to  what  the  Negro  physicians  are  doing  in  an 
organized  way,  a  tremendous  amount  of  work — a  great  deal  of  it 
unheard  of  outside  of  their  immediate  communities — is  being  done 
by  individual  physicians.  Without  doubt,  the  Negro  physician  is 
one  of  the  most  potent  forces  for  the  uplift  of  the  race,  and  there 
seems  to  be  a  growing  realization  on  his  part  of  what  his  great 
responsibilities  are  in  this  regard.  The  great  volume  of  his  work 
is  done  in  private,  in  his  office  consultations,  on  his  daily  rounds, 
in  the  churches,  the  secret  orders,  the  Sunday  schools,  the  Y.  M. 
C.  A.'s,  and  in  a  great  many  other  gatherings,  he  uses  his  influence 
for  the  betterment  of  racial  conditions,  and  at  the  same  time  for 
the  good  of  the  public,  for  it  cannot  be  denied  that  whatever  may 

(356) 


Health  Problems  of  the  Xegroes  113 

be  done  for  the  uplift  of  the  Negro  as  a  ruce,  at  the  same  time, 
helps  the  general  public. 

As  an  instance  of  the  above,  I  might  cite  a  few  examples :  Dr. 
A.  A.  Wyche,  a  Negro  physician  practicing  in  the  city  of  Charlotte, 
N.  C,  was  impressed  with  how  little  our  young  men  knew  about 
caring  for  their  general  health,  and  to  that  end  began  a  course  of 
Sunday  afternoon  lectures  to  boys  and  young  men  on  different 
subjects  pertaining  to  their  welfare.  He  said,  "It  was  surprising 
to  know  the  good  these  talks  have  done.  So  many  have  come 
to  me  privately  and  expressed  how  much  they  have  been  helped 
by  them."  He  is  now  preparing  a  series  of  lectures  to  be  given 
to  the  young  women.  He  is  also  giving  lectures,  once  a  week,  to 
trained  nurses,  to  the  Ministers'  Union,  and  the  graded  school 
teachers,  upon  hygiene  and  other  medical  subjects. 

At  Atlanta,  the  Fairhaven  Infirmary  is  operated  by  six  Negro 
physicians  and  is  doing  great  service  in  offering  shelter  at  very  rea- 
sonable rates.  The  nurses  from  the  nurse  training  department  of 
Morris  Brown  College,  are  sent  out  to  do  charity  work  under  the 
direction  of  physicians,  and  in  that  way  carry  relief  to  the  homes 
of  many  who  really  need  the  care  of  a  nurse,  but  could  not  pay 
for  such  services. 

Dr.  R.  F.  Boyd,  of  Nashville,  Tenn.,  writes,  "I  have  been 
deeply  interested  in  this  subject  for  a  number  of  years.  I  am  at 
present  president  of  the  Anti-tuberculosis  League  of  Nashville, 
which  holds  bi-monthly  meetings  in  the  various  churches,  instruct- 
ing the  people  as  to  the  origin,  prevention,  and  cure  of  'The  Great 
White  Plague.'  We  have  a  committee  that  distributes  sputum  cups 
to  those  who  are  subject  to  the  disease.  The  anti-spitting  law  has 
been  so  thoroughly  taught  that  now  most  of  the  people  obey  it 
almost  implicitly,  and  the  amount  of  spitting  on  the  floors,  cars, 
and  sidewalks,  is  very  much  reduced.  Since  we  began  this  cam- 
paign many  of  our  people  are  living  in  better  houses,  wear  better 
clothes,  and  are  more  careful  about  the  selection  and  preparation 
of  their  food.  The  churches,  school  houses,  and  public  buildings 
are  better  ventilated  and  the  mortality  is  lessened."  In  Lexington, 
the  local  Negro  medical  society  frequently  gives  lectures  on  health 
topics,  to  help  educate  the  people  in  the  prevention,  as  well  as 
treatment  of  disease,  and  special  effort  is  made  to  decrease  the 
mortality  from  tuberculosis. 

(357) 


114  ^/'^  Annals  of  the  American  Academy 

Some  of  the  Negro  insurance  companies  are  alive  to  the  issue, 
and  are  taking  steps  to  benefit  the  health  and  prolong  the  lives 
of  their  policy  holders.  The  North  Carolina  Mutual  and  Provident. 
Association,  of  Durham,  N.  C,  through  Dr.  A,  M.  Moore,  its 
medical  director,  advises  that  "The  most  potent  method  is  the  bed- 
side instruction  given  by  agents  and  superintendents  while  paying 
sick  claims.  This  comes  at  a  time  when  one  is  more  inclined  to 
receive  instruction.  Through  our  annual  agents'  conference,  I  give 
a  daily  lecture  on  sanitation,  contagions,  and  preventable  diseases, 
and  explain  the  danger  of  flies  and  water  supply,  as  well  as  buying 
second-hand  bedding,  carpets  or  clothes;  moving  into  houses  in 
which  contagious  sickness  has  been  prior,  especially  tuberculosis 
cases.  We  try  to  make  every  agent  a  sanitary  officer.  We  issue  a 
quarterly  bulletin  which  is  an  advertising  chart,  one  page  of  which 
is  devoted  to  'Sanitation  and  Health  Hints.' 

"I  have  succeeded  in  having  several  district  physicians'  socie- 
ties organized,  which  meet  in  diflferent  cities,  holding  public  meet- 
ings on  sanitation,  hygiene,  and  contagious  diseases.  We  are  con- 
stantly urging  the  agents,  by  circular  letters  and  talks,  to  strive 
in  every  way  to  better  the  condition  of  the  people  in  as  many  ways 
as  possible." 

The  Union  Mutual  Aid  Association,  of  Mobile,  Ala.,  distrib- 
utes through  its  agents,  from  time  to  time,  helpful  literature. 
Health  talks  are  given  to  the  agents  by  physicians.  The  agents 
are  required,  as  cause  and  opportunity  present,  to  speak  to  the 
policy  holders  on  improving  their  sanitary  surroundings. 

The  Union  Mutual  Aid  Association  is  inaugurating  this  year 
the  plan  of  giving  small  sums  of  money  to  the  health  department 
of  a  number  of  municipalities  of  the  state,  to  be  applied  to  sanitary 
improvement.  It  is  not  expected  that  the  fund  presented  will 
accomplish  very  much,  but  it  will  help  to  wake  the  colored  people 
up  to  the  fact  that  some  of  the  more  thoughtful  of  the  race  are 
alive  to  the  necessity  of  making  tangible  effort  along  this  line. 
The  company  is  planning  at  some  time  in  the  future  to  give  one 
yearly  medical  examination  to  its  policy  holders  at  any  time  the 
policy  holder,  in  good  standing,  may  elect  to  take  the  same. 

The  Hampton  Normal  and  Agricultural  Institute,  Hampton. 
Va..  is  doing  good  work  at  its  annual  conferences,  by  bringing? 
together  race  leaders  and  teachers,  physicians,  etc.,  and  among  other 

(358) 


Health  Problems  of  the  Negroes  115 

subjects  discussing  the  health  conditions  among  the  Negroes.  At 
the  1909  conference  the  Anti-tuberculosis  League  of  Virginia  was 
organized.  In  Elizabeth  City  county  they  are  trying  to  teach  the 
people  that  consumption  is  curable  if  taken  in  hand  in  time,  and  to 
apply  to  an  intelligent  physician  for  treatment,  instead  of  going  to 
the  druggist  or  taking  patent  medicines. 

Great  eflforts  are  being  made  in  Norfolk  to  prevent  the  spread 
of  consumption.  Some  four  years  ago  the  Anti-tuberculosis  League 
opened  a  free  clinic  for  the  treatment  of  consumption ;  three  days 
in  the  week  being  devoted  to  colored  patients,  and  for  the  year 
ending  September  30,  1909,  sixty-four  colored  patients  were  treated 
at  this  clinic.  "These  patients  were  supplied  with  sputum  cups, 
medicine,  and  printed  instructions  as  to  how  to  take  care  of  them- 
selves and  protect  themselves  from  infection,  thus  aiding  in  their 
own  cure  and  protecting  others  from  becoming  victims  of  the  dis- 
ease." In  October,  1909,  a  tuberculosis  clinic  was  opened  in  the 
city  of  Norfolk  for  the  colored  people,  with  a  trained  nurse  in 
charge,  and  seven  colored  physicians  on  the  clinic  staff  in  charge 
of  the  work.  The  city  paid  the  salary  of  the  nurses  and  expenses  of 
the  clinic ;  the  physicians  volunteered  their  services.  From  Octo- 
ber I,  1909,  to  June  I,  1910,  one  hundred  and  three  patients  were 
treated  at  this  clinic.  The  nurse  was  required  to  follow  up  the 
patients  who  attended  the  clinics  and  give  them  instructions  in  their 
houses.  One  thousand  six  hundred  and  eighty-five  such  visits  were 
made  during  the  past  year. 

An  Anti-tuberculosis  League  was  organized  in  Portsmouth. 
Va.',  April  30,  1909.  On  October  19,  1909,  the  Richmond  branch 
of  the  colored  Anti-tuberculosis  League  was  organized.  This  league 
has  held  a  series  of  public  meetings  at  churches.  The  third  Sunday 
in  January,  1910,  was  observed  as  tuberculosis  day.  A  sermon  on 
tuberculosis  was  preached  in  nearly  every  colored  church  in  Rich- 
mond, and  literature  bearing  on  the  subject  was  distributed.  The 
visiting  committee  of  the  league,  with  Miss  Mary  F.  Clark,  a  reg- 
istered nurse,  as  chairman,  did  very  important  work  by  affiliating 
with  the  city  health  authorities  in  hunting  up  tubercular  patients 
and  providing  proper  treatment.  The  committee  divided  the  city 
into  districts  and  nurses  were  assigned  to  each  district.  Food, 
clothing,  medicine,  and  even  fuel  have  been  furnished  for  the  sick. 
Persons  have  been  taught  how  to  care  for  the  sick,  and  how  to 

(359) 


ii6  The  Annals  of  the  American  Academy 

clean  and  care  for  their  houses,  and  in  some  instances  cooking 
lessons  were  given,  and  in  many  other  ways  this  committee  has 
helped  along  the  work.  The  membership  of  the  league  is  about 
four  hundred. 

Another  element  in  the  work  of  improving  the  health  of  the 
Negroes  is  the  rise  of  the  Negro  hospitals.  Dr.  George  W.  Hub- 
bard, dean  of  Meharry  Medical  College,  reports  that  the  graduates 
of  Meharry  own  and  control  six  institutions  of  this  kind  in  Tennes- 
see, two  in  Oklahoma,  five  in  Texas,  and  one  each  in  Missouri, 
Colorado  and  Georgia.  These  hospitals  and  sanatoriums  have  been 
well  patronized,  and  have  proven  financially  successful  and  have 
done  much  to  prevent  the  sufferings  of  the  colored  people.  Space 
will  not  permit  me  to  do  more  than  barely  mention  the  names  of  a 
great  many  others,  which  are  either  owned  or  controlled  by  Negroes : 
Provident  Hospital,  Chicago ;  Freedman's  Hospital,  Washington ; 
The  Frederick  Douglass  Memorial  Hospital.  Philadelphia ;  The  Ply- 
mouth Hospital  in  Boston ;  the  Provident  Hospital  in  St.  Louis ;  the 
Provident  Hospital  in  Baltimore,  Md. ;  the  Mercy  Hospital,  Phila- 
delphia ;  the  Richmond  Hospital,  and  the  Woman's  Central  League 
Hospital  in  Richmond,  Va. ;  the  Lincoln  Hospital  at  Durham,  N.  C. ; 
the  St.  Agnes  Hospital,  and  the  Shaw  University  Hospital  at 
Raleigh;  the  Hospital  and  Nurse  Training  School  at  Charleston, 
S.  C. ;  the  Charity  Hospital  at  Savannah,  Ga. ;  the  McVicar  Hos- 
pital at  Spellman  Seminary,  Atlanta;  the  Fairhaven  Infirmary, 
Atlanta;  the  Lamar  Hospital,  Augusta;  the  Burrus  Sanatorium, 
Augusta ;  the  Tuskegee  Institute  Hospital,  Tuskagee  Institute,  Ala. ; 
the  Hale  Infirmary,  Montgomery;  the  Northcross  Sanatorium, 
Montgomery ;  the  Cottage  Home  Infirmary,  Decatur ;  the  Old  Folks' 
Home  and  Hospital,  Birmingham ;  the  Burwell  Sanitarium,  Selma ; 
the  Harris  Infirmary,  Mobile ;  the  Kenniebrew  Sanatorium,  in  Jack- 
sonville, 111. ;  the  Red  Cross  Sanatorium,  Louisville,  Ky. ;  the  Burt 
Sanatorium,  Clarksville,  Tenn.  and  the  Perry  Sanatorium,  Kansas 
City,  Mo, 

Along  with  the  establishment  of  Negro  hospitals  have  arisen 
the  nurses'  training  schools.  Most  of  the  hospitals  mentioned  above 
have  connected  with  them  such  schools,  which  are  sending  out 
from  year  to  year,  a  large  number  of  colored  women,  who  are  not 
only  getting  ready  employment  among  the  white  people  but  are 

(360) 


Health  Problems  of  the  Negroes  117 

taking  their  share  of  the  burden  of  spreading  the  gospel  of  good 
health  and  right  living  among  Negroes. 

The  Associated  Charities  of  Birmingham,  Ala.,  employs  a  col- 
ored nurse  to  do  settlement  work,  and  furnishes  medical  attention 
without  charge  where  needed. 

Under  the  supervision  of  the  Visiting  Nurses'  Association,  of 
Chicago,  there  are  four  of  the  graduate  nurses  of  Provident  Hos- 
pital working  among  the  Negroes,  also  one  graduate  of  this  hospital 
is  a  member  of  the  school  nurses'  force.  Her  work  is  in  the  school, 
where  a  large  per  cent  of  the  pupils  are  Negroes.  In  all  proba- 
bility, in  the  near  future,  another  Negro  nurse  will  be  added  to  the 
tuberculosis  nurse  force.  A  tuberculosis  dispensary  is  about  to 
be  established  in  connection  with  Provident  Hospital. 

From  the  third  annual  report  of  the  Chicago  Tuberculosis 
Institute,  1908,  we  quote,  "Early  in  February  a  mass  meeting  of 
colored  people  was  held  in  Fulton  Hall.  The  result  of  this  meet- 
ing was  the  formation  of  a  strong  Negro  committee,  which  has 
done  active  work  during  the  year,  and  among  other  things  arranged 
for  a  dozen  or  more  Sunday  services  at  the  different  colored 
churches  in  the  city,  with  sermons  on  tuberculosis." 

Dr.  Anna  R.  Cooper,  a  colored  physician,  is  the  leader  of  a 
movement  to  establish  the  Paul  Lawrence  Dunbar  Sanitarium  for 
the  treatment  of  tuberculosis  among  Negroes.  "Governor  Hadley, 
of  Missouri,  has  recently  appointed  an  important  tuberculosis  com- 
mission. The  object  of  the  commission  is  to  find  out  just  what  the 
sanitary  conditions  are  among  the  Negroes."  The  Municipal  Health 
Leagues  were  recently  formed  by  both  the  white  and  colored  people 
of  Raleigh,  N.  C. 

At  Asheville,  N.  C,  in  both  colored  and  white  schools,  the 
modern  health  drinking  faucets  have  been  established,  and  other 
improvements  in  sanitation  have  been  installed. 

Much  is  being  done  to  improve  the  conditions  in  Savannah, 
Ga.  The  Men's  Sunday  Club,  colored,  of  that  city  was  organized 
in  1905.  It  has  had  an  average  attendance  since  organization  of 
two  hundred  people  About  every  colored  physician  in  the  city 
has  spoken  before  the  club.  In  the  summer  of  1905  a  regular  cam- 
paign for  health  improvement  was  carried  on.  All  the  colored 
churches  were  visited  and  addresses  made  at  each  one  by  physicians 

(361) 


ii8  The  Annals  of  the  American  Academy 

and  others.     Mothers'  clubs  were  organized  especially  to  assist  in 
improving  health  conditions. 

The  colored  Knights  of  Pythias  are  helping  to  restore  to 
health  a  great  many  people,  by  having  established,  in  1908,  at  Hot 
Springs,  Ark.,  a  bath  house  and  sanitarium,  where  thousands  of 
colored  people  have  gone  and  received  benefit  by  the  scientific  appli- 
cation of  the  waters. 

The  Tuskegee  Institute  has  been  alive  to  this  movement,  and 
in  numerous  ways  has  attempted  to  improve  conditions  in  the  school, 
in  the  surrounding  communities  and  in  other  places.  Several  forces 
have  co-operated  along  this  line. 

The  American  tuberculosis  exhibition,  under  the  direction  of  Mr. 
E.  G.  Routzahn,  paid  a  visit  to  the  Institute  in  December,  1908, 
remaining  several  days,  giving  stereopticon  lectures,  health  talks,  as 
well  as  displaying  the  exhibit  to  thousands  of  visitors,  including 
those  connected  with  the  school,  the  town  of  Tuskegee  and  the 
surrounding  community.  At  the  same  time  a  Tuberculosis  Con- 
gress was  held,  where  important  subjects  concerning  tuberculosis 
and  the  health  of  the  Negro  were  discussed. 

At  the  annual  Negro  conference  of  1909  the  subject,  "General 
Health  Conditions  of  Negroes  in  the  Southern  States,"  was  dis- 
cussed under  the  following  headings: 

"How  the  ministers  can  assist  in  bringing  about  better  health 
conditions ;"  "What  the  teacher  can  do  to  improve  our  health  con- 
ditions ;"  "How  the  doctor  can  assist  in  improving  our  general 
health  conditions;"  "Food  and  its  relations  to  health." 

The  late  Dr.  S.  P.  Lloyd,  of  Savannah,  Ga.,  led  the  discussion 
with  a  paper  on  health  conditions  from  the  physician's  standpoint. 
He  gave  as  the  general  causes  of  the  high  death  rate  among  the 
Negroes  poor  housing  conditions,  bad  landlords,  dissipation,  ignor- 
ance. He  advocated  improving  these  conditions  by  general  educa- 
tion, by  public  instruction  through  the  newspapers,  physicians  and 
ministers ;  that  the  municipalities  ought  to  see  that  better  houses  are 
built  for  the  Negroes.  He  also  advocated  the  systematic  and  perma- 
nent co-operation  of  the  Negroes  themselves. 

Bishop  Alstork  told  how  the  church  could  help.  During  the 
discussion  individual  communion  cups  were  advocated,  also  that 
lodges  should  hold  shorter  sessions ;  that  churches  should  not  be 
swept  out  Sundav  mornings  just  before  services. 

(362) 


Health  Problems  of  the  Negroes  119 

The  Tuskegee  Institute  has  also  assisted  in  this  work  by  the 
publication  of  bulletins  of  health,  under  the  direction  of  the  resi- 
dent physician.  These  topics  have  included,  "Tuberculosis,"  "Ty- 
phoid Fever,"  "The  Danger  of  Flies,"  an  dother  topics  along  sani- 
tary lines.  Stereopticon  lectures  on  tuberculosis,  general  sanitation, 
and  the  hookworm  disease  have  been  given,  and  other  health  talks 
to  students  and  teachers  in  the  school ;  also  to  the  Macon  County 
Farmers'  Institute,  the  Macon  County  Teachers'  Institute,  and  to 
some  of  the  Negro  churches. 

Four  years  ago,  in  connection  with  the  hospital,  there  was  in- 
augurated among  the  women,  what  is  known  as  the  Hospital  Aid 
Society,  composed  of  an  advisory  board  of  ten  women  and  members 
at  large,  from  the  school  and  community.  This  society  has  done  a 
great  deal  to  help  improve  conditions  at  the  Institute  Hospital;  to 
make  patients  and  nurses  more  comfortable ;  to  visit  the  sick  in  the 
community ;  in  many  instances  furnishing  medical  attention  and 
nurse's  services,  as  well  as  nourishment  and  medicine  for  those  too 
poor  to  pay  for  these  necessities.  It  also  maintains  a  charity  room 
and  bed  at  the  Institute  Hospital  in  which  suitable  indigent  patients 
are  taken  for  operative  and  other  treatment  free  of  charge.  At 
the  last  general  meeting  of  this  society  it  was  interesting  to  hear 
some  of  these  poor  patients  tell  with  gratitude  how  they  have  been 
helped. 

Quite  recently  all  of  the  school  children  attending  the  children's 
house,  about  two  hundred,  were  examined  by  the  resident  physician 
and  his  assistants.  A  great  many  defects  were  found,  parents  were 
advised  of  the  same,  and  directed  to  physicians,  dentists  and  special- 
ists, as  the  condition  required,  in  order  that  the  defects  might  be 
remedied. 

The  colored  women's  clubs  are  working  to  improve  the  homes 
through  reading  circles,  by  teaching  domestic  science,  and  by  other 
means.  Some  of  the  clubs  are  conducting  homes  for  aged  men  and 
women,  and  for  boys  and  girls.  The  Boys'  Reformatory  at  Mount 
Meigs,  Ala.,  where  thirty-seven  boys  and  two  men  are  cared  for,  on 
land  that  cost  five  hundred  dollars,  with  a  building  costing  twelve 
hundred  dollars,  is  an  example. 

The  Women's  Club  of  Tuskegee  Institute  is  especially  active. 
Houses  are  visited  with  a  view  to  teaching  the  people  the  simple 
principles  of  hygiene.  The  smallest  details  are  looked  after,  as  how 


I20  The  Annals  of  the  American  Academy 

to  prepare  and  serve  their  food,  how  and  when  to  bathe,  how  to  ven- 
tilate their  houses,  how  to  care  for  their  hair,  the  washing  of  their 
clothing,  cleaning  their  teeth,  sleeping  between  sheets,  and  all  such 
subjects  as  tend  to  improve  their  home  conditions.  The  special  sub- 
jects of  tuberculosis  and  typhoid  fever  have  been  discussed  before 
the  people  in  the  most  elementary  manner  possible.  Mrs.  Booker  T. 
Washington  says,  "The  people  themselves  are  most  responsive  and 
co-operative,  and  that  as  a  result  of  the  work  which  has  been  done 
along  these  lines,  great  improvements  have  been  made." 


(3(^4) 


PART  TWO 


Disease  Carriers— The  Control  of 
Causes 


^365) 


THE  RURAL  HEALTH  MOVEMENT. 


By  Ch.  Wardell  Stiles,  Ph.D., 
Professor  of  Zoology,  U.  S.  Public  Health  and  Marine-Hospital  Service. 


Rural  and  Urban  Health. — In  the  popular  conception,  rural 
life  is  more  healthful  than  urban,  and  people  have  considerable  to 
say  about  the  "pure  fresh  country  air."  Unfortunately,  however, 
fresh  air  is  only  one  of  the  factors  necessary  for  health,  and  by  itself 
"fresh  air"  will  not  overcome  our  great  national  sanitary  crime  of 
"soil  pollution."  In  plain  unvarnished  Anglo-Saxon,  "fresh  air" 
will  not  make  up  for  the  absence  of  a  privy  on  55.3  per  cent,  of  the 
4,822  American  farm  homes,  in  about  200  different  localities,  of 
which  I  have  records. 

In  rural  districts,  medical  attention  is  not  as  a  rule  so  easily 
available  as  in  cities,  partly  because  of  the  long  distances,  partly 
because  of  poor  roads,  partly  for  other  reasons,  and  in  genera! 
the  same  standard  of  medical  attention  is  relatively  more  expensive ; 
free  clinics  are  practically  unknown,  district  nursing  almost  unheard 
of  and  hospital  advantages  rare,  as  compared  with  these  advantages 
in  the  cities.  Further,  while  the  urban  inhabitants  receive  more  or 
less  protection  on  the  part  of  local  boards  of  health,  the  inhabitants 
of  the  open  country  scarcely  know  what  a  health  officer  is,  except 
in  case  of  an  outbreak  of  smallpox.  In  the  city,  the  average  Amer- 
can  woman  has  the  services  of  a  physician  in  case  of  child-birth ;  in 
the  rural  districts  the  average  American  woman,  so  far  as  I  have 
been  able  to  learn,  is  not  protected  by  medical  attention  at  such  time. 

Origin  of  the  Present  Movement. — For  more  than  two  decades 
past,  the  American  government  has  shown  a  keen  interest  in  the 
health  of  the  farmers'  swine,  but  it  remained  for  ex-President 
Roosevelt  to  initiate  a  more  active  interest  in  the  health  of  the  farm- 
ers' wives  and  children.  Roosevelt's  Commission  on  Country  Life 
was  in  fact  the  real  starting  point  of  the  present  nation-wide  active 
movement  for  a  betterment  of  health  conditions  in  our  open  country. 
Naturally  there  was  certain  preliminary  work  in  this  line  in  various 
places,  especially  by  some  of  the  state  boards  of  health,  and  there 

(3^7) 


124  The  Annals  of  the  American  Academy 

were  certain  investigations  into  rural  medical  conditions,  especially 
by  the  boards  of  health  of  Georgia  and  Florida,  and  by  the  Depart- 
ment of  Agriculture,  the  Bureau  of  Labor,  and  the  Public  Health 
and  Marine-Hospital  Service.  But  it  was  President  Roosevelt's 
Commission  on  Country  Life,  despite  the  ridicule  heaped  upon  it  by 
part  of  the  daily  press,  that  opened  the  eyes  of  persons  in  many 
states  interested  in  agriculture  to  the  self-evident  fact  that  the  life 
of  the  wife  of  the  poorer  farmer  is  not  what  it  is  so  often  thought 
to  be  and  that  her  health  is  more  important  than  that  of  the  swine. 
Among  the  many  indirect  results  of  the  work  of  the  Country  Life 
Commission  must  be  included  the  tremendously  increased  activity 
on  the  part  of  at  least  nine  state  boards  of  health. 

Stains  of  Rural  Sanitation. — If  any  one  wishes  to  see  how  far 
behind  the  present  status  of  sanitary  science  this  country  really  is, 
he  should  visit  a  number  of  small  farms  and  note  under  what  con- 
dition the  milk  is  kept;  he  should  examine  the  toilet  facilities  and 
see  how  the  flies  infect  the  "fresh  country  milk"  with  human  feces ; 
how  poor  the  ventilation  is ;  how,  for  instance,  the  death  rate  from 
tuberculosis  would  be  even  greater  than  it  is  at  present,  were  it  not 
that  some  fresh  air  does  enter  the  house  because  of  cracks  between 
the  boards. 

These  conditions  are  not  typical  for  any  one  particular  part  of 
the  country  and  for  that  section  alone,  although  they  are  accentuated 
in  localities  with  more  than  one  race,  as  in  those  sections  where  the 
Chinaman,  the  Indian,  the  Japanese,  the  Mexican,  and  the  Negro 
are  found  in  numbers.  It  is  popularly  supposed  that  one  must  go 
to  the  mountains  of  North  Carolina  to  find  really  wretched  sanitary 
conditions ;  but  this  popular  idea  was  shattered  to  atoms  by  the 
Commission  on  Country  Life  as  it  brought  out  the  facts  of  the  un- 
sanitary conditions  of  the  so-called  "bunk-houses"  on  some  of  the 
California  fruit  ranches,  or  of  some  of  the  conditions  just  this  side 
of  the  Canadian  border,  or  in  Illinois,  or  in  Nebraska  and  Iowa,  and 
of  the  miserable  hovels  of  the  Mexican  "Greaser."  Any  sanitary 
missionary  in  any  part  of  the  country  can  find  enough  to  keep  him 
busy  for  some  time  if  he  undertakes  to  improve  the  sanitary  condi- 
tions of  the  farms  within  a  radius  of  ten  miles  of  his  home — the 
farms  which  are  supplying  his  table  with  milk,  butter,  berries,  cel- 
ery, lettuce,  and  with  these,  human  excreta.    That  the  conditions  in 

(368) 


The  Rural  Health  Movement  125 

question  are  not  present  on  some  of  the  large  and  rich  estates  is  to 
be  admitted.  That  they  are  present  and  the  rule  on  the  poorer  and 
even  on  the  average  farm  can  not  be  truthfully  denied.  In  fact,  the 
sanitary  crimes,  especially  the  great  crime  of  soil  pollution,  are  so 
flagrant  that  to  the  practiced  eye  they  are  often  recognizable  even 
from  the  window  of  a  car  as  the  train  passes  through  a  given  dis- 
trict. Soil  pollution  is  evident  between  New  Haven  and  Boston ; 
near  Lake  Sunapee ;  it  extends  across  to  the  Pacific,  down  to  lower 
California,  eastward  to  Florida,  northward  to  Maine ;  but  it  in- 
creases in  degree  and  danger  as  soon  as  the  population  becomes 
mixed,  and  as  the  warmer  climates  are  approached. 

In  some  states,  the  sanitation  surrounding  the  rural  schools  is, 
relatively  speaking,  excellent,  but  in  many  of  our  states  rural  school 
sanitation  is  a  disgrace  to  our  land.  The  church  sanitation  is  usu- 
ally, so  far  as  my  observations  go,  very,  very  far  inferior  to  that  of 
the  public  schools  and  indicates  that  the  average  rural  clergyman 
has  forgotten  the  advice  given  in  Deut.  23.  12-13. 

Result  of  Rural  Insanitary  Conditions. — Typhoid  fever  is  a 
typical  filth  disease.  Any  person  who  contracts  typhoid  has 
recently  swallowed  some  germs  from  the  urine  or  feces  of  some 
other  person.  Flies  are  typically  filth  animals,  as  they  breed  and 
feed  in  and  on  filth,  notably  horse  and  human  excreta.  Let  any  one 
think  how  common  flies  are  in  the  average  American  dining  room 
and  kitchen  and  he  can  form  some  slight  conception  of  the  copro- 
phagous  habit  of  the  American  nation.  In  the  cities,  the  sewer 
system  decreases  both  the  number  and  the  clanger  of  flies;  in  the 
rural  districts,  where  the  sewer  is  replaced  by  the  privy,  which  is 
rarely  cleaned,  and  where  almost  every  house  is  near  a  manure  pile, 
flies  abound,  water  is  in  general  more  of  a  luxury,  coprophagy,  un- 
intentional of  course,  naturally  increases,  and  with  this  there  is  an 
increase  of  filth  diseases,  such  as  typhoid;  further,  there  is  likely 
to  be  an  increase  in  all  soil  pollution  diseases,  such  as  amebic  dysen- 
tery, Cochin  China  diarrhea,  hookworm  diseases,  etc.  The  personal 
habits  of  the  average  farmer  are  not  so  clean  as  those  of  the  urban- 
ite ;  spitting  is  general,  chewing  and  snuflF  taking  common,  especially 
in  certain  districts,  and  as  a  result  when,  as  is  more  common  than 
popularly  supposed,  a  case  of  tuberculosis  occurs  in  the  family 
the  disease  is  likely  to  spread  rapidly. 

(369) 


126  The  Annals  of  the  American  Academy 

Conservatism  of  Rural  Population. — The  conservatism  of  the 
rural  population  is  proverbial.  It  need  not  therefore  be  expected 
that  conditions  will  be  changed  in  a  day.  In  fact,  it  will  take  at 
least  a  generation  to  bring  rural  sanitation  to  where  it  should  be. 
The  American  farmer,  at  least  in  my  experience,  is  not  abnormally 
concerned  about  the  health  of  his  wife  and  children,  whatever  may 
be  his  solicitude  for  the  health  of  his  mares,  cows,  and  sows.  The 
farmer's  wife,  however,  is  deeply  interested  in  the  health  of  her 
children,  and  it  is  chiefly  through  the  wife  and  children  that  a  change 
in  the  present,  often  medieval,  conditions  will  be  brought  about. 

Plan  of  Campaign. — The  most  striking  point  in  regard  to  the 
present  campaign  for  improvement  in  rural  conditions  is  the  way  the 
health  officers  and  the  school  teachers  have  made  friends  and  are 
working  together.  Of  77,127  answers  to  the  question  "Are  the  sani- 
tary conditions  on  the  farms  in  your  locality  satisfactory?"  those 
from  the  school  teachers  came  nearest  to  the  real  conditions  as  evi- 
denced by  the  typhoid  death  rate.  The  present  miserable  sanitary 
conditions  of  the  school  houses  are  not  due  to  the  teachers  but  to 
the  school  boards.  The  rural  school  teachers  are  teaching  sanita- 
tion in  plain  English  and  are  eager  to  learn  more  that  they  may 
impart  to  the  rising  generation,  and  when,  say  fifty  years  from  now, 
the  history  of  the  present  movement  for  improved  rural  sanitation  is 
written,  there  are  certain  persons  who  will  be  generally  recognized 
as  the  people  who  made  it  possible,  who  launched  it,  and  who  car- 
ried it  out.  Were  I  to  prophesy  who  would  be  mentioned  in  this 
connection  I  would  say:  Theodore  Roosevelt,  John  D.  Rockefeller, 
Walter  Wyman,  the  field  men  of  the  various  boards  of  health,  and 
the  rural  school  teachers. 

A  Great  Need. — Aside  from  the  factors  at  work  in  various  parts 
of  the  country,  looking  to  better  rural  sanitation  in  general,  there 
are  a  few,  very,  very  few,  rural  district  nurses,  and  a  few  Y.  M.  C. 
A.  rural  secretaries  who  are  doing  work  of  a  more  special  nature,  the 
former  helping  the  mothers  and  girls, the  latter  helping  the  men.  Both 
of  these  movements  are  really  in  their  infancy,  but  they  both  deserve 
the  greatest  good  will  and  encouragement  on  the  part  of  all  people. 
The  influence  for  good  of  a  sensible  rural  "district  nurse"  is  enough 
to  make  any  person  wish  he  were  a  millionaire  for  the  one  purpose 
of  endowing  this  movement,  one  of  the  newest  welfare  policies. 

(370) 


SANITATION  IN  RURAL  COMMUNITIES 


By  Charles  E.  North,  M.D., 
New  York. 


Sanitation  is  man's  best  defense  against  his  siirroundings.  Dis- 
ease and  death  have  become  recognized  as  due  not  only  to  inherited 
weaknesses  of  the  individual,  but  in  a  large  measure  to  the  influ- 
ence of  the  external  world  upon  him.  This  outer  world  is  the 
medium  which  contributes  the  bacteria  of  infectious  disease.  One 
after  another  the  diseases  in  the  list  of  causes  of  death  have  been 
discovered  to  be  due  to  bacteria  which  invade  the  human  body  and 
destroy  it  by  the  growth  of  their  colonies  and  the  formation  of 
poisonous  products. 

Public  interest  has  followed  the  lead  of  the  scientific  investiga- 
tors. Under  the  name  of  sanitary  science  the  fight  against  these 
poisonous  plants,  so-called  bacteria,  is  being  carried  on.  By  sani- 
tation the  numerous  avenues  by  which  the  bacteria  are  accustomed 
to  travel  to  produce  their  outbreaks  of  disease  are  being  closed  up, 
their  resting  places  are  being  destroyed,  and  the  original  sources 
of  infection  are  being  discovered. 

The  principles  involved  in  the  sanitation  of  rural  communities 
differ  in  no  respect  from  those  of  sanitary  science  in  general.  The 
gathering  together  of  men  into  large  cities  or  small  towns  or  iso- 
lated dwellings  modifies  only  the  method  of  applying  these  prin- 
ciples. 

Rural  Population 

In  the  year  1790  the  population  of  the  United  States  was  about 
four  million  persons  of  which  96.7  per  cent  lived  in  a  rural  state 
and  3.3  per  cent  lived  in  cities.  In  the  year  1900,  with  a  population 
of  about  eighty  million,  there  was  66.9  per  cent  living  in  rural  dis- 
tricts and  33.1  per  cent  in  cities.  These  figures  may  be  one  reason 
for  the  often  repeated  statement  that  the  farm  is  being  deserted 
and  the  people  flocking  to  the  cities.  There  is  certainly  no  doubt 
that  some  of  the  farming  districts  in  the  eastern  part  of  the  coun- 
try, particularly  in  New  England,  are  suffering  from  depopulation; 

(371) 


128  The  Annals  of  the  American  Academy 

but  on  the  other  hand  it  is  equally  certain  that  in  the  middle  and 
western  part  of  the  country  the  rural  districts  are  becoming  more 
thickly  settled.  The  rural  situation  appears  more  plainly  if  the 
figures  are  tabulated  as  follows: 


Year. 

Population. 

Urban. 

Rural. 

1790 

4,000,000 

132,000 

3,868,000 

1900 

80,000,000 

26,480,000 

53,520,000 

Thus,  while  the  number  of  persons  living  in  cities  is  relatively 
larger  than  during  the  century  past,  the  rural  communities  have 
received  an  actual  addition  of  over  fifty  million  inhabitants  while 
the  cities  have  increased  by  twenty-six  millions,  or  by  one  half  the 
number. 

Absence  of  Official  Supervision  of  Rural  Sanitation 

The  mere  fact  that  country  life  is  more  natural  to  man  and 
that  he  is  by  nature  an  outdoor  animal,  tends  in  some  respects  to 
make  him  revert  toward  the  savage  mode  of  existence,  while  sojourn- 
ing in  the  country.  The  more  ignorant  and  untrained  he  is,  the 
more  is  this  likely  to  be  true.  In  the  city  he  is  a  part  of  a  civilized 
community  and  subject  to  its  laws  and  customs.  In  the  country, 
on  the  other  hand,  he  is  chiefly  a  law  unto  himself. 

Among  the  institutions  established  for  better  administration 
of  city  life  is  the  city  department  of  health,  whose  function  is  the 
enforcement  of  rules  and  regulations  controlling  the  character  of 
buildings  in  which  the  people  live,  the  protection  of  their  foods  and 
drinks  against  transmissible  diseases,  the  proper  removal  of  all 
household  wastes,  and  the  care  of  the  sick,  and  especially  of  those 
suflfering  from  transmissible  disease.  In  large  cities  this  control 
is  comparatively  rigid  and  efficient.  In  smaller  towns  it  is  much 
less  so,  while  in  rural  communities  it  is  still  less.  Thus,  in  a  large 
city  public  authorities  define  the  number  of  windows  and  the  amount 
of  ventilation  required  for  dwellings.  The  water  supply,  the  sew- 
erage system,  the  garbage  and  ash  removal  are  all  in  charge  of 
public  officers.  Milk,  meat,  vegetables,  fruits  and  all  other  foods 
are  inspected  and  under  the  control  of  the  health  authorities.  Hos- 
pitals and  sanitariums  are  established  for  the  sick  and  for  the  quar- 
antining of  contagious  diseases.  In  rural  districts,  on  the  other 
hand,  each  man's  home  is  as  he  may  desire  to  make  it.     His  water 

(372) 


Sanitation  in  Rural  Communities  129 

and  sewerage  system,  his  method  of  disposal  of  waste,  his  milk  and 
food  supplies  are  all  under  his  own  personal  control.  Public 
authorities  do  not  interfere  with  him  in  his  management  of  such 
matters.  The  quarantining  of  infectious  diseases  is  usually  the  only 
function  performed  by  his  town  or  county  health  officers,  to  pro- 
tect him  from  preventable  diseases. 

Death  Rates — Rural  vs.  Urban 

In  the  year  1908,  seventeen  states  in  the  Union  gathered  records 
of  the  deaths  occurring  within  their  boundaries.  These  included 
all  of  the  New  England  states,  the  Middle  Atlantic  states  with  the 
exception  of  Delaware,  four  states  in  the  middle  West,  and  three 
in  the  extreme  West.  None  of  the  Southern  states  furnished  any 
reliable  statistics  and  the  greater  part  of  the  middle  and  western 
states  are  also  lacking  in  this  respect.  Consequently  the  statistics 
received  concerned  chiefly  the  northeastern  part  of  the  country, 
and  for  this  reason  the  reports  must  be  accepted  with  some  reser- 
vation. When  the  great  Negro  population  in  the  South  and  the 
large  agricultural  districts  of  the  middle  and  western  part  of  the 
country  are  included,  the  figures  will  without  doubt  be  consider- 
ably modified.  A  partial  list  of  the  deaths  occurring  in  the  regis- 
tration area,  in  cities  and  in  rural  communities  is  as  follows: 

Deaths  per  100,000. 
Disease.  Cities.  RuraL 

All  causes    1,654-6  1,396.0 

Typhoid     24.5  24.3 

Malaria    i.i  1-7 

Smallpox     0.1  0.2 

Measles     13.S  8.2 

Scarlet  fever   17.4  8.0 

Whooping  cough    10.4  1 1.9 

Diphtheria  and  croup  27.9  17.3 

Influenza    16.8  27.9 

All  other  epidemic  diseases 10.6  13.3 

Tuberculosis  of  the  lungs 169.  i  ii7-3 

All  other  forms  of  tuberculosis . .  29.2  19.3 

Cancer    80.5  68.0 

Tumor    i.i  0.9 

Diabetes   151  l3-6 

Meningitis   21.4  17.1 

Other  nervous  diseases 131-6  1532 

Diseases  circulatory  system  190.4  I7S,.I 

(373) 


130  TJie  Annals  of  the  American  Academy 

Deaths  per  100,000. 

Disease.  Cities.  RiiraL 

Pneumonia   107.8  82.9 

Other  respiratory  diseases 103.3  61.9 

Diarrhea    and    enteritis 133.5  96.9 

Other  diseases  digestive  system.  85.8  74.3 

Bright's  disease  and  nephritis...  113.9  Ji.y 

Infancy    84.3  58.9 

Suicide    20.4  14.4 

Accident    96.8  lOI.O 

III  defined  26.9  26.7 

All  other  causes 120.1  122.7 

Unknown    i.o  5.3 

In  the  first  place  it  appears  that  the  total  number  of  deaths 
from  all  causes  is  less  in  rural  districts  than  in  cities.  If  the  per- 
centage given  in  the  table  be  applied  to  the  estimated  population 
at  the  present  time,  assuming  that  the  percentage  of  persons  living 
in  cities  is  approximately  the  same  as  it  was  in  the  year  1900,  we 
would  obtain  the  following  results. 

Total  population,  1910,  92,000,000;  of  which  about  6^  per  cent 
live  in  rural  communities,  or  61,640,000;  while  the  city  population, 
representing  about  33  per  cent  amounts  to  30,360,000.  Applying 
the  death  rate  in  the  above  table  for  cities  to  the  city  population, 
we  would  have  a  total  of  502,336  deaths  occurring  in  the  cities. 
Taking  an  equal  population  in  rural  districts  and  applying  the 
rural  death  rate,  we  obtain  423,825  deaths  in  an  equivalent  rural 
population.  This  gives  a  difference  of  78,511  more  deaths  occur- 
ring in  the  cities  in  the  year  than  in  an  equivalent  population 
living  in  rural  districts.  It  may  not  be  unfair,  therefore,  to  attribute 
this  excess  of  deaths  to  the  unfavorable  conditions  of  city  life.  It 
seems  to  me  that  we  must  include  in  our  list  of  causes  of  death 
"city  life,"  and  place  it  in  the  list  with  tuberculosis,  pneumonia, 
and  other  causes. 

Some  of  the  comparative  death  rates  from  specific  diseases  in 
the  table  are  of  great  interest.  It  is  noteworthy  that  the  typhoid 
death  rate  is  about  the  same  both  in  cities  and  in  rural  commu- 
nities ;  on  the  other  hand  there  is  more  malaria  in  the  country 
than  in  the  city.  The  deaths  from  measles,  scarlet  fever,  diph- 
theria, however,  are  much  more  numerous  in  cities  than  in  the 
country.  All  forms  of  tuberculosis  and  pneumonia  are  also  greater 
in  cities.     Diarrheal  diseases,  which  include  infant  diarrheas,  are 

(374) 


Sanitation  in  Rural  Communities  131 

also  greater  in  cities ;  Bright's  disease  is  considerably  greater,  and 
diseases  of  the  circulatory  system ;  while  deaths  from  accident  on 
the  other  hand  are  greater  in  the  country  districts. 

Tuberculosis,  pneumonia,  bronchitis  to  which  overcrowding 
and  impure  air  contribute,  and  measles,  scarlet  fever,  and  diphtheria 
are  transmitted  from  person  to  person  to  which  overcrowding  gives 
opportunities  and  are  naturally  greater  in  cities.  The  impure  milk 
and  summer  heat  of  cities  account  for  the  excess  of  infant  diar- 
rheas. Lack  of  exercise,  the  sedentary  life  of  business  men,  and 
improper  food  would  account  to  a  certain  extent  for  the  excess  of 
deaths  from  Bright's  disease  in  cities.  The  presence  of  mosquitoes 
in  country  districts  is  a  reason  for  the  higher  death  rate  from 
malaria.  Impure  water  supplies  and  milk  supplies  is  the  chief  rea- 
son for  the  typhoid  death  rate  being  at  least  as  great  in  the  country 
districts  as  in  the  cities.  There  are,  of  course,  numerous  diflferences 
in  the  table  which  cannot  be  readily  explained.  Cancer  is  not 
sufficiently  understood.  The  greater  death  rate  from  nervous  dis- 
eases in  the  country  districts  is  also  not  so  easy  to  understand. 

It  is  obvious  on  the  whole  that  there  are  a  number  of  diseases 
in  the  list  which  cause  deaths  in  rural  communities  which  can 
be  largely  prevented  by  proper  sanitary  measures.  These  diseases 
are  the  following:  Typhoid,  malaria,  smallpox,  measles,  scarlet 
fever,  whooping  cough,  diphtheria,  influenza,  tuberculosis,  menin- 
gitis, pneumonia  and  diarrheas. 

Morbidity — Rufal  vs.  Urban 

It  is  not  possible  to  secure  accurate  statistics  of  the  kind  and 
of  the  extent  of  illness  existing  in  rural  districts  as  compared  with 
other  sections.  One  can  see  how  in  general  the  number  of  dis- 
eased persons  at  any  one  time  in  rural  districts  is  likely  to  be  less 
than  the  number  in  cities,  because  the  death  rate  is  less.  Yet  this 
only  applies  to  those  diseases  which  are  common  to  both  city  and 
country,  and  which  are  common  causes  of  death.  There  are  dis- 
eases on  the  other  hand  which  are  not  common  to  the  country  and 
city,  and  which  may  not  be  included  in  the  usual  list  of  mortality 
statistics. 

Prominent  among  the  diseases  peculiar  to  country  districts  must 
be  mentioned  infection  with  intestinal  parasites.  In  Porto  Rico 
from  90  per  cent  to  100  per  cent  of  the  population  in  the  year  1900 

(375) 


132  The  Annals  of  the  American  Academy 

were  infected  with  hookworm.  Over  31  per  cent  were  infected  with 
a  parasite  known  as  the  eelworm,  while  infections  with  other  para- 
sites existed  to  a  less  degree.  In  the  middle  and  northern  United 
States  7.69  per  cent  of  the  population  are  infected  with  the  whip- 
worm and  with  other  parasites  to  a  lesser  degree.  In  the  Southern 
states  the  number  of  persons  infected  with  hookworm  exceed  the 
infections  with  all  other  parasites  combined. 

In  the  Philippines  80  per  cent  of  the  population  are  infected 
with  intestinal  parasites  of  one  or  more  kinds.  All  of  these  infec- 
tions are  peculiar  to  country  districts  and  are  not  found  so  com- 
monly in  cities.  They  fall  into  the  catalogue  of  preventable  infec- 
tions and  for  that  reason  come  within  the  scope  of  the  diseases  to 
be  considered  by  sanitary  science. 

Household  Sanitation 

In  the  application  of  sanitary  measures  to  rural  communities, 
as  in  fact  to  any  community,  perhaps  the  first  item  to  be  considered 
is  the  cleanliness  of  the  dwelling.  More  attention  has  been  given 
to  this  branch  of  sanitation  in  the  past  than  to  any  other.  In  fact 
it  has  not  been  the  sanitary  expert  or  the  professor  of  sanitary 
science  who  has  emphasized  the  importance  of  cleanliness  in  the 
household,  so  much  as  the  housekeepers  themselves.  Dutch  house- 
wives for  centuries  have  been  proverbial.  In  certain  parts  of  New 
England  extreme  attention  is  given  by  housewives  to  certain  features 
of  cleanliness.  One  may  visit  almost  any  rural  community  in  the 
New  England  states  and  be  impressed  with  the  degree  of  anxiety 
shown  by  the  housewives  for  the  removal  of  dust  and  the  sweeping 
of  rooms.  The  semi-annual  "house-cleaning"  is  almost  a  'religious 
ceremony.  It  is,  perhaps,  unfair  to  remark  that  the  degree  of  atten- 
tion given  to  this  branch  of  sanitation  is  out  of  all  proportion  to 
its  importance,  and  that  the  very  home  in  which  it  is  exercised  to 
the  highest  degree  may  be  drinking  polluted  water  and  may  pos- 
sess unsanitary  methods  for  the  disposal  of  sewage,  drainage  and 
household  waste,  and  is  very  likely  to  have  a  large  manure  pile 
within  easy  distance  of  the  kitchen  door.  It  is  a  fact  that  these 
external  conditions  have  only  come  to  be  recognized  as  important 
factors  to  the  health  of  the  household  in  comparatively  recent 
years. 


Sanitation  in  Rural  Communities  133 

Dish  Washing 

The  necessity  for  internal  cleanliness  of  the  building,  its  floors 
and  walls,  of  rooms  and  of  the  removal  of  dust  and  dirt  is  so 
deeply  impressed  upon  the  housekeeper  in  rural  communities  that 
it  needs  no  further  emphasis.  There  is  one  feature  of  household 
sanitation,  however,  which  does  deserve  special  attention.  This 
is  the  washing  of  dishes  and  other  utensils  used  in  the  kitchen 
and  dining  room.  The  transmission  of  the  bacteria  inhabiting  the 
nose  and  mouth  and  throat  and  lungs,  and  such  bacteria  as  may 
be  clinging  to  the  hands  and  fingers  is  particularly  easy  by  means 
of  the  kitchen  and  table  ware.  The  handling  which  such  imple- 
ments receive  during  the  family  meal  is  one  which  readily  conveys 
any  personal  infections  to  their  surfaces.  Influenza,  tuberculosis, 
pneumonia,  bronchitis,  sore-throat,  tonsilitis,  diphtheria,  scarlet  fever, 
measles,  typhoid  fever,  dysentery,  and  other  infections  which  cause 
discharges  from  any  portion  of  the  body,  particularly  from  the 
mouth  and  nose,  can  become  attached  to  table  ware  in  a  way  which 
prevents  them  from  being  removed  unless  they  are  thoroughly 
washed  and  sterilized.  It  is  a  common  thing  for  knives  and  forks 
used  by  a  person  infected  with  tuberculosis  at  one  meal  to  be  used 
by  some  other  person  at  the  next  meal,  and  in  this  way  serious 
chances  of  infection  may  occur.  Consequently  the  washing  of 
these  implements  is  a  most  important  matter. 

A  survey  of  the  methods  in  common  use  in  the  average  house- 
hold shows  that  this  operation  is  often  a  hasty  one  or  is  left  in  the 
hands  of  some  ignorant  servant  or  even  when  done  under  the  super- 
vision of  the  mistress  herself  is  not  done  in  a  scientific  manner. 
Soaps  which  do  not  dissolve  grease  or  remove  clinging  matter  are 
used  instead  of  solutions  of  soda.  The  use  of  one  pan  of  water 
unchanged,  or  infrequently  changed  is  common  rather  than  several 
pans  of  water  frequently  changed  so  that  all  utensils  rhall  receive 
a  thoroughly  clean  rinsing.  Dish  rags  are  used  instead  of  brushes, 
and  the  final  scalding  with  boiling  hot  water  is  frequently  omitted. 
By  the  use  of  brushes,  solutions  of  soda,  a  thoroughly  clean  rins- 
ing, and  finally  scalding  water,  dishes  and  table  ware  can  be  washed 
and  sterilized  so  that  they  stand  no  chance  of  conveying  infection 
from  person  to  person. 

(377) 


134  The  Annals  of  the  American  Academy 

Air 

One  of  the  highest  places  in  the  list  of  causes  of  death  in 
rural  communities  is  occupied  by  tuberculosis.  The  only  disease 
approaching  it  as  a  cause  of  death  is  heart  disease  and  other  dis- 
eases of  the  circulatory  system.  At  first  thought,  the  open  air 
life  of  persons  residing  in  rural  districts  is  hard  to  reconcile  with 
the  great  extent  of  tuberculosis  in  such  communities.  It  is,  of 
course,  necessary  to  remember  that  tuberculosis  is  caused  by  bac- 
teria and  that  it  is  commonly  a  chronic  disease  which  means  that 
the  person  infected  therewith  carries  the  bacteria  in  his  system 
for  a  considerable  length  of  time  and  is  usually  a  source  of  infec- 
tion to  those  among  whom  he  dwells.  Houses  have  been  credited 
with  being  haunted  by  tuberculosis.  Records  show  that  persons 
dwelling  in  certain  houses  come  down  with  the  disease  while  those 
dwelling  in  other  houses  do  not.  In  large  cities,  departments  of 
health  show  by  their  maps  certain  blocks,  and  particularly  tenement 
houses,  in  which  large  numbers  of  cases  of  tuberculosis  have 
occurred  year  after  year.  In  rural  communities  the  same  thing  is 
true,  and  certain  houses  are  pointed  to  as  being  the  home  of  this 
disease;  but  while  it  is  true  to  an  extent  that  the  floors  and  walls 
of  dwellings  may  for  a  limited  period  retain  tubercular  infection, 
we  now  know  that  the  transmission  of  the  disease  is  usually  more 
direct  and  that  it  is  the  fresh  discharges  from  tuberculous  persons 
that  are  most  to  be  dreaded,  and  are  the  principal  causes  for  the 
prevalence  of  this  disease.  It  is  the  carriers  of  tuberculosis  living 
in  rural  communities  who  transmit  the  disease  to  the  members  of 
their  families  and  to  those  with  whom  they  come  in  contact. 

But  in  the  pure  air  of  the  country  one  would  naturally  expect 
to  find  a  very  much  smaller  death  rate  from  tuberculosis  than  in 
the  cities.  Summarizing  the  figures  in  the  previous  table  it  appears 
that  in  cities  the  death  rate  from  tuberculosis  is  198.3,  while  in 
rural  districts  it  is  136.6  per  hundred  thousand  population. 

One  of  the  chief  reasons  for  this  high  mortality  in  rural  dis- 
tricts is  the  practice  of  sleeping  with  closed  windows.  This  is 
almost  universal  on  farms  and  in  villages.  While  the  farmer  may 
breathe  pure  air  all  day  long  yet  when  he  retires  at  night  he  con- 
ceives it  to  be  necessary  for  his  comfort  to  have  his  bedroom  window 
tightly  closed.     Whether  the  reason  for  this  be  that  in  the  winter 

(378) 


Sanitation  in  Rural  Communities  135 

time  he  fears  the  cold  and  in  the  summer  time  he  fears  inva- 
sion of  insects,  yet  it  is  a  common  experience  to  find  the  air  of 
country  bedrooms  foul  and  close.  For  this  reason  at  that  period 
in  the  twenty-four  hours  when  the  process  of  repair  is  uppermost, 
the  dweller  in  rural  districts  probably  breathes  air  as  foul,  if  not 
more  so,  than  the  dweller  in  the  large  city. 

The  ventilation  of  the  country  house  is  rendered  comparatively 
easy  because  open  fire  places  are  so  common.  The  proper  manage- 
ment of  the  windows  of  the  dwelling  is  all  that  is  necessary  to 
insure  an  abundant  supply  of  fresh  air  to  the  inhabitants  at  all 
times.  The  use  of  stoves,  open  fire  places  and  kerosene  lamps 
which  rapidly  consume  oxygen  makes  window  ventilation  even  more 
necessary. 

In  the  country  house  proper  attention  must  be  given  to  the  con- 
dition of  cellars  to  prevent  dampness  and  damp  air  on  the  first  floor 
and  to  the  removal  of  all  decaying  vegetables  and  refuse  and  to 
the  prevention  of  odors  from  manure  and  from  the  stable. 

Light 

The  necessity  of  sufficient  light  to  the  country  dwelling  is  so 
elementary  that  it  seems  hardly  necessary  to  mention,  yet  it  is 
worthy  of  remark  because  of  the  common  practise  in  rural  commu- 
nities of  keeping  certain  portions  of  the  dwelling  in  constant  dark- 
ness. Parlors  which  are  only  used  for  weddings  and  funerals  are 
common,  and  shutters  and  curtains  are  used  to  darken  rooms  to 
prevent  carpets  and  upholstery  from  fading.  But  the  absence  of 
light  results  in  dampness  and  deprives  these  rooms  of  the  benefits 
of  nature's  own  best  disinfectant.  I  think,  however,  that  the  disin- 
fecting power  of  light  as  applied  to  dwellings  has  been  somewhat 
over-emphasized.  At  the  same  time  it  must  be  remembered  that 
human  beings  were  not  made  to  live  in  darkness  and  that  light 
has  an  important  stimulating  action  on  the  human  organism.  The 
late  lamented  Commissioner  Waring  was  accustomed  to  say  that 
"Faded  carpets  were  of  much  less  importance  than  faded  cheeks." 

Water  Supply 

If  one  were  to  attempt  to  determine  just  what  class  of  dis- 
eases was  increased  by  existence  in  rural  districts,  one  would  nat- 
urally examine  the  results  upon  those  who  have  been  accustomed 

(379) 


136  The  Annals  of  the  American  Academy 

to  dwell  in  cities  when  a  change  is  made  to  a  rural  existence.  In 
this  connection  we  may  refer  to  the  history  of  disease  in  armies 
on  the  march  and  in  time  of  war,  when  large  bodies  of  men 
leave  their  settled  camps  and  enter  into  a  strictly  rural  type  of 
life.  In  the  Mexican  war  the  chief  cause  of  death  was  diarrhea; 
in  the  Crimea,  typhus,  malaria  and  typhoid  were  the  causes  of 
death ;  in  the  Civil  war  dysenteiy  and  malaria  were  at  the  head 
of  the  list ;  in  the  late  Spanish  war  the  order  was  malaria,  dysen- 
tery and  typhoid ;  in  the  Boer  war  the  chief  diseases  were  typhoid 
and  dysentery ;  in  the  Japanese  army  beri-beri,  dysentery  and 
typhoid  were  the  prevailing  diseases.  Inflammation  of  the  intes- 
tines were  in  most  of  these  instances  the  cause  of  death. 

The  water  supply  is  without  question  the  readiest  means  for 
the  transmission  of  infections  which  cause  intestinal  disease.  This 
is  because  the  bacteria  of  intestinal  infections  so  often  contami- 
nate water  supplies  through  contact  with  sewage  or  the  drainage 
from  outhouses.  The  dug  well  is  the  most  common  form  of  water 
supply  used  by  rural  dwellers.  It  is  usually  the  easiest  method  for 
obtaining  water  and  can  be  located  at  a  point  convenient  to  the 
kitchen  door.  It  is  also  a  common  practice  to  have  out-door  privies 
located  at  a  convenient  distance  to  the  house,  and  in  many  instances 
their  location  is  one  which  makes  contamination  of  the  well  easy. 
Well  water  is  also  frequently  contaminated  by  barn-yard  drainage 
and  stable  drainage.  Surface  washings  from  the  door-yard  and 
from  the  laundry  and  from  the  kitchen  sink  may  also  find  their  way 
into  the  well.  A  large  number  of  examinations  have  been  made  of 
wells  on  farms  both  in  the  east  and  in  the  western  part  of  the 
United  States,  and  a  summary  of  the  results  shows  that  at  least 
60  per  cent  of  the  wells  examined  were  seriously  contaminated  with 
the  bacteria  which  are  identified  with  sewage. 

Cisterns  and  springs  in  like  manner  may  be  contaminated.  Out- 
breaks of  typhoid  fever  from  these  contaminations  are  so  numerous 
that  the  literature  is  filled  with  their  reports.  I  may  quote  one 
instance  which  came  under  my  personal  observation,  namely,  that 
of  an  Episcopal  parsonage  on  Long  Island,  where  a  number  of 
cases  of  typhoid  appeared  in  the  family  without  apparent  cause. 
Drinking  water  was  obtained  from  a  cement  cistern  which  was 
supplied  by  rain  water  collected  on  the  slate  roof.  This  water 
supply  seemed  to  be  most  carefully  protected  from  contaminations, 

(380) 


Sanitation  in  Rural  Communities  137 

The  house  was  equipped  with  modern  plumbing,  and  the  drainage 
ran  through  sewer  pipes  to  a  cesspool  which  was  located  several 
hundred  feet  away  from  the  cistern.  When  a  lantern  was  lowered 
into  the  cistern  black  streaks  were  noted  oozing  through  a  crack  in 
the  cement  wall.  When  an  excavation  was  made  in  the  earth  at 
the  side  of  the  cistern  a  break  was  discovered  in  the  sewer  pipe 
leading  from  the  house,  and  the  ground  between  the  pipe  and  the 
cistern  was  saturated  with  sewage.  There  is  no  doubt  that  some 
visitor  to  the  family  caused  the  first  typhoid  case  by  polluting  the 
drinking  water,  and  that  the  disease  was  continued  by  further  pol- 
lutions of  succeeding  cases. 

A  pure  water  supply  is  positively  necessary  for  health.  A 
reasonable  per  diem  allowance  is  from  fifty  to  seventy-five  gallons 
per  capita.  The  running  water  of  brooks  is  a  safe  source  of  supply, 
provided  there  are  no  dwellings  which  drain  into  it.  Rivers  and 
lakes,  while  often  a  source  of  supply  for  cities,  can  be  of  use 
only  to  the  rural  districts  located  on  their  shores.  Wells  and 
cisterns  must  continue  to  be  the  main  reliance  of  country  dwellings. 
Among  these  the  driven  and  artesian  wells  are  the  best  type.  A 
reason  for  this  is  that  when  properly  constructed  they  do  not  receive 
surface  washings  or  surface  water,  but  are  sealed  at  the  top  and 
draw  their  supply  from  a  considerable  depth  beneath  the  surface. 
Deep  ground  water  usually  comes  from  a  considerable  distance, 
and  has  passed  through  such  an  extent  of  soil  and  rock  that  it  has 
been  thoroughly  purified. 

Dug  wells,  which  draw  their  water  only  from  the  surface  layers 
of  the  soil,  may  furnish  safe  supplies  only  when  located  at  a  con- 
siderable distance  from  possible  sources  of  pollution,  and  when 
properly  protected  against  surface  washings.  One  good  method  of 
protection  is  to  dig  a  circular  trench  three  or  four  feet  deep  at  a 
distance  of  about  six  feet  from  the  edge  of  the  well  which  can  be 
filled  with  rough  stone  so  that  all  surface  washings  will  fall  into 
this  trench  rather  than  into  the  well ;  by  a  suitable  underdrain 
leading  off  from  this  ditch  all  surface  water  can  be  led  away  from 
the  well.  Another  safeguard  is  to  close  entirely  the  top  of  the 
well,  using  no  ropes  or  buckets,  but  having  a  pump  attached  which 
discharges  the  water  considerably  to  one  side  of  the  well  opening, 
thereby  preventing  any  of  the  discharged  water  from  falling  back 
into  the  well. 

(38T) 


138  The  Annals  of  the  American  Academy 

There  are  now  a  number  of  types  of  efficient  filters  at  reason- 
able prices,  which  can  be  supplied  for  country  residences  and  can 
be  attached  to  wells  or  cisterns  or  other  sources  of  supply,  and 
when  properly  operated  will  remove  any  chance  pollutions  that 
may  occur  in  the  waters.  In  emergencies  sterilization  of  the  water 
can  be  performed  by  boiling-  and  by  the  use  of  chemicals,  among 
which  chloride  of  lime  is  best. 

Foods 

Fresh  food  of  all  kinds  is  associated  in  one's  mind  with  coun- 
try life.  Consequently  at  first  thought  one  would  assume  that  sani- 
tary science  had  little  comment  to  make  on  this  subject.  In  the 
matter  of  vegetables  and  fruits  there  is  in  fact  but  little  to  be  said, 
not  only  for  the  reason  that  such  fruits  are  usually  produced  on 
the  premises,  but  because  their  preservation  has  been  such  a  mat- 
ter of  study  and  practice  in  rural  communities  that  most  country 
housewives  are  proficient  in  the  canning  and  drying  of  fruits  and 
in  the  proper  care  of  winter  vegetables. 

In  the  matter  of  meat  and  fish,  however,  there  are  some  im- 
provements that  can  be  made.  The  lack  of  ice  and  facilities  for 
refrigeration  is  very  common.  The  cellar  is  often  the  only  means 
for  keeping  food  cool.  The  temperature  of  a  cellar  is  not  suffi- 
ciently cool  to  furnish  any  real  preservative  action  on  meats  or  on 
fish.  The  decay  of  meat  and  fish  is  caused  by  the  bacteria  of 
putrefaction  which  produce  poisonous  substances  known  as 
"ptomaines.''  Ptomaine  poisoning  is  the  name  given  to  the  severe 
symptoms  which  follow  the  eating  of  decayed  meat  and  other  foods. 

It  is  therefore  to  be  recommended  that  in  those  parts  of  the 
country  at  least  where  ice  forms  in  the  winter,  rural  communities 
make  a  practice  of  gathering  ice  and  using  it  for  refrigeration 
during  the  warm  months  of  the  year. 

Meat  and  pork  used  in  country  districts  are  for  the  most  part 
killed  by  local  butchers  and  are  a  local  product.  The  meat  of  these 
animals  is  not  subject  to  scientific  inspection  and  for  this  reason 
may  at  times  be  diseased.  Tuberculosis  has  become  very  common 
among  beef  cattle  in  this  country.  In  Europe  it  is  estimated  that 
forty  per  cent  of  the  cattle  are  diseased  with  bovine  tuberculosis ; 
and  in  the  United  States  a  summary  of  the  various  estimates  range 
from  thirty-three  to  three  per  cent,  with  the  disease  probably  on 

(382) 


Sanitation  in  Rural  Communities  139 

the  increase.  From  the  examinations  which  have  been  made  of 
human  beings  afflicted  with  tuberculosis  it  appears  that  the  bovine 
type  is  practically  limited  to  children.  For  this  reason  it  seems 
likely  that  it  is  not  often  transmitted  through  diseased  beef.  The 
cooking  of  meat  may  be  one  reason  for  this.  At  the  same  time 
it  would  be  in  the  interest  of  the  inhabitants  of  rural  communities 
if  a  better  system  of  meat  inspection  could  be  established. 

A  more  serious  threat  against  the  health  of  rural  communities 
is  found  in  the  parasites  which  inhabit  both  beef  and  pork. 
The  term  "measly"  beef  and  "measly"  pork  is  used  to  describe 
the  flesh  of  animals  marked  by  the  larvae  of  tape-worms.  Unless 
such  meat  is  thoroughly  cooked  it  causes  tape-worms  to  develop 
in  the  intestines  of  those  who  consume  it.  Swine  are  particularly 
likely  to  be  infected  with  this  disease,  and  the  thorough  cooking 
of  pork  and  of  ham  must  be  carried  out  to  prevent  the  infection 
from  being  transmitted. 

Trichina  is  the  name  of  a  species  of  worm  which  infects  at 
least  two  ])cr  cent  of  the  hogs  in  the  United  States.  These  also 
infect  man  and  cause  much  physical  discomfort.  They  are  easily 
killed  in  pork  by  proper  cooking. 

Milk 

A  leading  physician  in  one  of  our  large  cities  stated  to  the 
writer  that  it  was  a  great  pleasure  for  him  to  take  a  trip  to  the 
country  so  that  he  could  secure  a  drink  of  milk  which  had  in  it  the 
real  "cowey"  flavor.  He  expressed  surprise  that  the  flavor  which 
he  so  desired  was  entirely  absent  from  the  glass  of  milk  he  was 
drinking  on  the  premises  of  a  certified  dairy.  It  was  necessary  to 
explain  to  him  that  this  "cowey"  taste  was  not  natural  to  milk, 
'xit  was  due  to  its  pollution  with  cow  manure.  His  remark,  how- 
ever, illustrates  how  common  the  pollution  of  milk  with  cow  manure 
is  because  he  is  no  exception  in  believing  that  the  so-called  "cowey" 
flavor  is  natural  to  milk. 

Milk  in  the  country  is  fresh,  but  it  is  not  necessarily  clean  or 
free  from  infectious  diseases.  Those  who  dwell  in  country  districts 
have  the  great  advantage  of  securing  milk  before  it  has  become 
many  hours  old ;  but  in  many  instances  the  milk  is  obtained  from 
cattle  which  are  diseased,  and  is  handled  in  a  manner  which  exposes 
it  to  contaminations  with  dirt  and  with  bacteria. 

(3«3) 


140  The  Annals  of  the  American  Academy 

A  prominent  veterinarian  who  has  examined  over  twelve  thou- 
sand cows  in  New  York  State  by  means  of  the  tuberciihn  test,  as- 
serts that  in  his  opinion  sixty  per  cent  of  the  dairy  cattle  furnishing 
milk  to  New  York  City  are  infected  with  tuberculosis  in  some 
degree.  Examinations  made  of  milk  sold  on  the  streets  of  New 
York  City  and  of  the  cities  of  Washington  and  Chicago,  and  of 
Leipsic,  Germany,  show  that  the  bacteria  of  tuberculosis  are 
present  in  more  than  ten  per  cent  of  the  samples  examined.  Con- 
sequently we  must  believe  that  a  considerable  part  of  the  milk  which 
is  used  in  rural  communities  is  infected  with  tuberculosis.  This 
is  a  matter  more  serious  for  the  children  and  babies  than  for  the 
adults. 

Manure  and  dirt  from  the  stable  or  from  the  cows'  udders  and 
coats,  from  the  hands  of  the  milkers  and  from  the  milking  pails 
and  pans  are  all  offensive  to  the  sense  of  decency,  if  not  a  menace 
to  health. 

Bacteria  of  typhoid  fever,  scarlet  fever  and  diphtheria  are 
often  transmitted  through  milk.  These  bacteria  get  into  milk  from 
persons  engaged  in  milk  handling  or  from  the  water  in  which  milk 
utensils  are  washed. 

It  is  possible  for  the  average  farmer  to  produce  a  clean  and 
safe  milk  for  his  own  use  and  for  the  use  of  his  neighbors  by  very 
simple  and  inexpensive  means.  His  cattle  can  be  kept  in  perfect 
health  with  the  assistance  of  a  competent  veterinarian,  and  it  is 
to  the  financial  interest  of  the  farmer  in  the  long  run  to  see  that 
this  is  done. 

By  the  use  of  tar  paper  and  whitewash  and  home-made  cement 
he  can  have  a  sanitary  cow  stable  at  small  cost. 

A  covered  milking  pail  or  milking  can  in  place  of  the  old- 
fashioned  wide-mouthed  pail  will  keep  nine-tenths  of  the  dirt  and 
bacteria  out  of  the  milk  during  milking  time.  By  the  use  of  a 
brush  and  a  solution  of  soda  followed  by  a  rinsing  in  perfectly 
clean  water  and  a  final  scalding  with  boiling  water  all  milk  utensils 
can  be  kept  clean  and  sterile. 

Milk  for  family  use  may  be  had  twice  daily  and  should  be 
used  on  the  farm  as  fresh  as  possible.  For  all  milk  that  is  to  be 
carried  to  a  village  or  town,  preservation  with  ice  is  positively 
necessary.  Where  ice  cannot  be  had  upon  the  farm,  several  farmers 
in  the  district  can  combine  their  interests,  and  by  co-operation  se- 

(384) 


Sanitation  in  Rural  Communities  141 

cure  a  supply  of  ice  at  some  central  place  to  which  their  milk  can 
be  carried  for  refrigeration.  This  plan  makes  the  cost  to  each 
farmer  a  very  reasonable  one. 

Sewage  Disposal 

Perhaps  the  most  difficult  problem  to  be  faced  in  rural  com- 
munities is  the  proper  handling  of  sewage.  This  includes  not  only 
the  bowel  discharges  of  the  inhabitants,  but  the  drainage  from 
laundries,  kitchens,  barnyards,  etc.  Large  cities  are  usually  located 
upon  rivers  and  lakes,  into  which  the  sewage  can  be  discharged 
and  disposed  of  by  dilution  with  great  quantities  of  water. '  Rural 
communities,  which  are  for  the  most  part  located  inland,  have  no 
such  facilities  and  must  find  some  means  of  disposing  of  their 
sewage  in  the  earth. 

The  discharge  of  sewage  into  a  brook  or  running  stream  is  a 
most  dangerous  proceeding  because  of  the  chance  that  the  water 
of  this  stream  will  be  used  further  down  for  drinking  purposes. 
Many  of  the  states  have  laws  prohibiting  the  pollution  of  streams 
in  this  manner,  and  therefore  streams  should  not  be  looked  upon 
as  available  for  these  purposes.  In  the  Southern  states  conditions 
are  probably  worse  than  in  any  other  part  of  the  country.  The 
climate  encourages  a  continued  outdoor  existence  throughout  the 
year  and  many  of  the  inhabitants  are  ignorant  and  unsanitary  in 
their  habits.  This  leads  to  the  promiscuous  distribution  of  bowel 
discharges  on  the  ground  in  country  districts.  Such  exposure  is 
believed  to  be  the  chief  cause  of  the  wide-spread  infection  of  hook- 
worm. The  hookworm  inhabits  the  bowels  and  infects  the  soil 
wherever  discharges  are  deposited.  A  large  percentage  of  the  in- 
habitants wear  no  shoes,  and  the  mud  clinging  to  their  bare  feet 
often  contains  the  parasites.  The  hookworm  pierces  the  skin  of 
the  feet  and  finds  its  way  to  the  intestines,  where  the  eggs  of  the 
next  generation  are  hatched. 

Bowel  discharges  of  typhoid  patients  are  of  course  a  most 
serious  threat  against  the  health  of  those  who  dwell  in  the  neigh- 
borhood. If  such  a  discharge  is  made  on  open  ground  it  is  exposed 
to  flies,  which  may  carry  the  infection  to  the  nearest  kitchen  and 
transmit  it  to  food  or  to  milk.  Many  cases  are  recorded  where 
rain  has  washed  the  infection  from  such  discharges  into  a  nearby 

(385) 


142  The  Annals  of  the  American  Academy 

well  or  stream  which  was  used  as  a  water  supply,  and  which  pro- 
duced typhoid  fever  in  the  persons  drinking  the  water. 

One  case  may  be  mentioned  which  came  under  the  writer '-s 
observation,  where  Italians,  camped  on  the  bank  of  a  brook,  de- 
posited their  bowel  discharges  on  open  ground.  One  of  their  num- 
ber having  typhoid  fever,  thereby  infected  the  waters  of  the  brook 
which  was  used  as  a  source  of  supply  by  five  different  villages,  in 
which  there  occurred  immediately  a  typhoid  outbreak  of  over  forty 
cases  and  seven  deaths. 

Cesspools  and  wooden  privies  are  the  most  common  estab- 
lishments in  rural  districts  for  the  disposal  of  the  bowel  discharges 
of  the  inhabitants.  The  vaults  of  these  are  often  made  of  loose 
stones  without  any  provision  for  overflow.  There  is  consequently 
not  only  a  leaching  through  nearby  soil,  but  an  actual  overflow  on 
to  the  surface  of  the  soil.  From  this  exposure,  both  by  means  of 
insects  flying  to  the  houses  and  by  the  washing  of  rains  into  water 
supplies,  infections  can  be  easily  carried  to  the  inhabitants  of  the 
surrounding  country. 

The  earth  closet  is  the  readiest  means  for  the  sanitary  dis- 
posal of  the  bowel  discharges  of  those  who  dwell  in  isolated  houses. 
This  consists  of  the  ordinary  small  wooden  building  supplied  with 
water-tight  cans  of  metal  into  which  the  discharges  are  received 
and  into  which  is  thrown  at  the  same  time  a  certain  quantity  of 
fresh  earth  shoveled  from  a  box  kept  in  the  closet.  Lime  is  also  a 
very  good  material  to  mix  with  such  discharges.  The  iron  recep- 
tacle should  receive  a  sufficient  amount  of  earth  to  absorb  liquids, 
so  that  when  it  is  filled  the  contents  are  solid.  It  should,  of  course, 
be  frequently  emptied  and  carried  to  a  remote  place  where  the 
contents  can  be  buried  at  a  suitable  depth  and  covered  up  with 
earth.  This  method  of  disposal  is  safe,  simple,  and  cheap^  and  can 
be  adopted  by  any  isolated  farm-house. 

Cesspools  are  only  permissible  when  they  are  made  tight  and 
small  and  frequently  cleaned,  and  are  not  allowed  to  overflow  on 
the  surface  of  the  soil  or  to  leak  into  the  surrounding  soil  in  a 
way  which  is  likely  to  contaminate  water  supplies. 

The  burning  of  bowel  discharges,  as  it  is  carried  out  at  times 
in  armies,  is  an  ideal  method  because  it  absolutely  destroys  all 
chances  of  infection.  The  use  of  disinfectants,  such  as  chloride 
of  lime,  is  also  to  be  highlv  recommended. 

(386) 


Sanitation  in  Rural  Communities  143 

Where  houses  are  gathered  together  in  groups  and  in  small 
villages  ok  camps  it  is  economy  to  provide  a  common  system  of 
sewage  disposal,  so  that  all  sewage  will  be  delivered  through  pipes 
to  one  plant.  Such  a  plant  should  be  so  located  that  it  will  not  con- 
stitute a  nuisance  to  any  of  the  dwellings.  Some  of  the  simpler 
from  among  the  many  and  expensive  plans  for  the  disposal  of 
sewage  are  adapted  for  use  in  small  communities.  Among  these 
may  be  mentioned  the  system  called  "sub-surface  irrigation,"  in 
which  shallow  ditches  beneath  the  soil  intermittently  receive  the 
sewage  and  it  is  digested  and  absorbed  by  the  biolytical  processes 
of  the  upper  layers  of  earth.  Another  method  adapted  for  this  pur- 
pose is  one  where  a  preliminary  screening  and  filtration  is  fol- 
lowed by  the  disinfection  of  the  fluid  effluent,  with  such  chemicals 
as  chloride  of  lime.  The  handling  of  propositions  of  this  kind  is 
of  course  beyond  the  powers  of  the  average  citizen,  and  such  in- 
stallations must  necessarily  be  placed  in  the  hands  of  specialists. 

Water  from  sinks  and  laundries  in  farm  houses  is  usually  al- 
lowed to  run  out  on  to  the  surface  of  the  ground,  where  it  is  likely 
to  collect  and  to  form  a  wet  and  unsightly  and  ill-smelling  place. 
Such  water  should  be  led  away  from  the  house  through  pipes, 
where  it  can  be  caught  in  a  cesspool  filled  with  gravel  or  broken 
stone.  Most  of  the  solids  will  be  retained  in  this  way  and  the 
liquid  portion  carried  off  by  seepage  into  the  surrounding  soil. 
The  location  of  such  a  drain  should  of  course  be  one  which  is  re- 
mote from  the  source  of  water  supply. 

Garbage  Disposal 

A  pig  pen  is  a  valuable  institution  in  one  respect,  namely,  that 
in  many  parts  of  the  country  it  is  a  ready  and  sure  means  for  gar- 
bage disposal.  All  waste  food  and  kitchen  refuse  can  be  carried  to 
the  pigs  and  will  be  consumed  by  them,  so  that  there  is  no  nuisance 
other  than  the  pig  pen  itself.  Where  garbage  cannot  be  gotten 
rid  of  in  this  manner  it  is  necessary  to  devise  a  system  of  garbage 
disposal  which  will  prevent  the  indiscriminate  throwing  of  waste 
food  on  to  the  ground  in  the  neighborhood  of  the  house.  Accumu- 
lations of  this  sort  are  bad  from  a  sanitary  standpoint  not  only 
because  they  are  unsightly  and  cause  offensive  odors,  but  particu- 
larly because  they  attract  flies  which  breed  and  multiply  in  such 
places  and  may  transmit  infection  to  the  household. 

(387) 


144  ^^^^  Annals  of  the  American  Academy 

Wet  garbage  and  food  of  all  kinds  should  be  kept  separate 
from  ashes  and  from  trash.  A  water-tight  can  is  the  best  sort  of 
receptacle  for  garbage.  Ashes  should  be  placed  in  another  can 
and  trash  can  be  placed  in  a  box.  Ashes  are  not  seriously  ob- 
jectionable in  character.  They  can  be  utilized  for  walks  and  road- 
ways and  thrown  upon  the  ground  without  harm.  Cans  of  wet 
garbage  and  trash  are  best  disposed  of  by  burning.  Rural  com- 
munities composed  of  several  houses  or  villages  can  afford  to  main- 
tain a  crematory  of  simple  form  where  all  of  these  wastes  can  be 
burned  up.  One  of  the  simplest  of  these  is  called  a  "rock  pile" 
crematory.  It  consists  of  stones  so  grouped  together  that  liquids 
will  filter  down  between  them  while  solids  are  retained  on  the 
surface.  A  good  supply  of  air  is  received  through  the  crevices  in 
the  stones  and  all  of  the  contents  can  be  easily  burned  up. 

In  isolated  houses,  where  it  is  not  convenient  to  maintain  a 
crematory  combustible  trash  can  be  burned  up  while  wet  garbage 
can  be  carted  off  and  buried  or  dumped  at  a  distance  remote  from 
the  dwelling. 

Manure 

The  manure  pile  has  lately  gained  recognition  as  deserving 
more  than  ordinary  consideration  by  the  sanitarian  because  it  is 
the  headquarters  for  flies  in  its  immediate  neighborhood.  Flies 
breed  best  in  manure.  The  manure  pile  has  for  many  years  been 
looked  upon  as  a  necessary  part  of  the  farm  business.  The  wealth 
of  a  farmer  used  to  be  judged  by  the  size  of  the  manure  pile  in  his 
barnyard.  The  study  of  agriculture  has  now  shown  that  the  accu- 
mulation of  manure  from  horse  stables  and  cow  stables  in  a  pile 
is  not  the  best  method  for  its  preservation,  but  that  great  waste 
takes  place  due  to  the  fermentations  and  escape  of  gases  from  such 
a  deposit.  The  largest  dairies  now  make  a  practice  of  spreading 
all  manure  upon  the  ground  daily  and  none  of  it  is  accumulated. 

The  odors  from  the  manure  pile  while  offensive  are  not  neces- 
sarily injurious  to  health.  One  of  the  most  recent  faults  found 
with  these  accumulations  is  due  to  the  discovery  that  the  germs  of 
tuberculosis  are  very  often  discharged  through  the  bowels  of 
tuberculous  cattle,  and  consequently  the  manure  pile  may  be  filled 
with  this  infection.  The  breeding  of  flies  in  the  manure  pile  is 
one  of  the  reasons  why  the  household  is  afflicted  with  flies  in  the 

(388) 


Sanitation  in  Rural  Communities  145 

summer  time.  These  insects  are  a  menace  to  health  not  only 
because  of  the  material  which  they  may  carry  from  the  manure 
pile,  but  because  they  may  travel  to  the  surrounding  country  and 
feed  on  matter  which  contains  infection.  Much  of  the  typhoid 
which  occurs  during  the  summer  and  fall  months  is  attributed  by 
some  authorities  to  the  prevalence  of  flies  during  those  seasons  of 
the  year. 

Recently  the  writer  made  an  investigation  of  a  typhoid  fever 
outbreak  in  which  at  least  twenty  cases  occurring  in  x)ne  summer 
encampment  were  probably  due  to  the  infection  of  food  with  the 
germs  of  typhoid  fever  by  flies  which  had  been  bred  in  a  nearby 
manure  pile  which  at  times  received  the  discharges  of  a  man  who 
was  afflicted  with  typhoid  in  a  chronic  form. 

The  best  remedy  for  the  manure  pile  is  to  have  none.  If  it  is 
necessary  it  should  be  placed  as  far  as  possible  from  the  house. 
If  this  cannot  be  done  another  easy  remedy  is  to  surround  it  with 
screens  so  that  flies  cannot  gain  access  to  it.  The  application  of 
disinfectants,  such  as  chloride  of  lime  and  ordinary  unslacked  lime, 
are  also  measures  which  will  prevent  odors  and  make  the  heap  un- 
attractive for  flies. 

Mosquitoes 

The  mosquito  is  now  held  chiefly  accountable  for  the  spread 
of  malaria,  yellow  fever,  black  water  fever,  dengue,  and  filariasis. 
Malaria  is  the  disease  of  greatest  interest  to  the  inhabitants  of  the 
United  States,  because  the  other  diseases  are  comparatively  rare 
in  this  country.  Mosquitoes  lay  their  eggs  in  water.  The  eggs 
float  on  the  surface  of  the  water  and  hatch  out,  forming  larvae 
which  Mve  near  the  surface.  These  in  a  short  time  grow  and  de- 
velop into  adult  mosquitoes  whch  fly  up  from  the  surface  of  the 
water  and  begin  their  adult  life.  Standing  water  is  necessary  for 
these  purposes.  Running  brooks  and  rivers  are  not  breeding 
grounds  for  these  insects.  In  Cuba,  Mexico  and  Central  America 
the  common  source  of  water  supply  is  cisterns.  Mosquitoes  have 
access  to  many  of  these  and  use  them  as  breeding  grounds.  The 
substitution  of  city  water  supplies  by  pipe  lines  and  the  abandon- 
ment of  cisterns  have  reduced  the  number  of  mosquitoes  and  the 
diseases  contracted  from  them  in  a  remarkable  manner  in  some 
of  these  cities.    One  of  the  most  remarkable  instances  is  the  banish- 

(389) 


I4(J  ^/it'  Annals  of  the  American  ^icademy 

ment  of  yellow  fever  from  the  city  of  Havana,  which  was  accom- 
plished not  only  by  removing  the  cisterns  and  standing  water  but 
by  protecting  buildings  with  proper  screens  against  these  insects." 
In  the  Panama  Canal  the  fight  against  the  mosquito  is  the  real 
secret  of  the  success  of  the  American  enterprise  in  that  region. 

Malaria  is  transmitted  by  the  mosquito  through  the  biting  of 
some  person  suffering  from  that  disease  whose  blood  contains  the 
parasites  which  are  sucked  with  it  into  the  body  of  the  mosquito 
where  the  parasites  remain.  Such  a  mosquito  may  later  on  bite 
some  other  person  and  inject  the  parasites  into  his  blood,  giving 
rise  to  malaria  in  him.  The  vital  statistics  show  a  greater  preva- 
lence of  malaria  in  rural  communities  than  in  cities.  It  is  obvious 
that  cities  are  not  so  favorable  to  the  growth  of  mosquitoes  as  are 
rural  districts.  In  the  country  there  is  not  only  likely  to  be  some 
standing  water,  but  a  greater  abundance  of  the  green  plants  on 
which  the  mosquito  commonly  feeds. 

The  fight  against  mosquitoes  in  rural  districts  must  be  carried 
on  first  by  the  drainage  of  all  standing  water  in  the  neighborhcw  d 
of  the  house.  Even  old  tin  cans  and  pails  and  the  rain  barrel  and 
the  horse  trough  are  places  where  mosquitoes  will  breed.  Where 
they  have  become  a  pest  and  standing  water  cannot  be  drained  off, 
the  application  of  kerosene  to  the  water  every  two  weeks  will  pre- 
vent the  multiplication  of  these  insects.  The  kerosene  spreads  over 
the  surface  of  the  water  and  kills  the  eggs  and  the  larvae. 

When  insects  have  once  invaded  a  house  so  that  they  cannot 
be  driven  out  by  ordinary  means  they  can  be  killed  by  fumigation. 
Sulphur  is  the  best  material  to  use  for  this  purpose.  The  burning 
of  a  sulphur  candle  in  a  properly  closed  room  will  kill  all  the  mos- 
quitoes and  other  insects.  The  screening  of  windows  and  of  doors 
is  another  important  item  in  the  prevention  of  malaria.  Screening 
is  being  constantly  more  widely  adopted,  and  it  is  a  practice  which 
should  be  insisted  upon  in  rural  districts. 

This  screening  should  include  not  only  the  house  but  also  the 
place  where  garbage  is  kept,  and  if  the  garbage-can  itself  is  not 
covered  a  screen  cover  is  a  good  thing  to  use.  The  privy  must  also 
be  thoroughly  screened  against  flies,  so  that  by  no  possibility  can 
they  gain  access  to  the  discharges  contained  there.  Where  cases  of 
malaria  exist  the  patients  should  be  thoroughly  protected  against 
mosquitoes,  for  in  this  way  it  is  possible  to  prevent  the  disease 

(390) 


Sanitation  /;.  Rural  Communities  147 

from  being  transmitted  from  a  malarial  patient  to  those  who  dwell 
in  the  neighborhood. 

Education 

The  most  important  of  all  sanitary  considerations  in  connection 
with  rural  communities  is  the  matter  of  education.  The  people 
themselves  must  be  informed  concerning  the  progress  of  sanitary 
science  and  how  to  follow  a  system  of  clean  living  if  they  are  to 
gain  the  benefits  which  are  to  be  derived  from  sanitary  knowledge. 
The  best  place  to  begin  sanitary  education  is  in  the  district  schools. 
The  old  system  of  teaching  physiology  and  hygiene  and  the  "nature 
studies"  which  are  now  used  in  the  district  schools  are  not  sufficient 
to  give  the  children  correct  ideas  on  sanitary  matters.  There  is  a 
movement  on  foot  at  the  present  time  to  bring  about  this  kind  of 
sanitary  instruction  in  the  public  schools.  It  is  delayed  in  the  first 
place  because  the  teachers  themselves  are  comparatively  ignorant 
on  sanitary  matters.  It  is  therefore  necessary  to  establish  a  system 
of  sanitary  instruction  for  school  teachers,  and  through  them  even- 
tually the  children  in  the  schools  can  be  reached.  Children  should 
be  made  familiar  with  the  meaning  of  the  wortl  "bacteria"  and 
especially  taught  the  nature  of  infectious  diseases  so  that  they  will 
know  them  by  name.  They  should  also  be  clearly  instructed  as 
to  the  cause  of  infectious  diseases,  and  jjarticularly  such  diseases 
as  are  likely  to  occur  in  their  own  part  of  the  country.  Simple  but 
important  instruction  on  water  supplies,  milk  supplies,  and  sewage 
can  be  given. 

Next  to  the  district  schools,  the  state  and  county  IxDards  of 
health  can  play  a  most  important  part  in  education  by  the  regular 
publication  and  distribution  of  bulletins  on  public  health  matters. 
The  activity  displayed  by  the  Department  of  Agriculture  and  the 
experiment  stations  established  in  diflFerent  states  is  an  illustration 
of  how  this  kind  of  work  can  be  done.  Persons  living  in  rural  com- 
munities are  all  familiar  with  the  bulletins  on  acfriculture.  If  they 
could  be  made  equally  familiar  with  bulletins  on  public  health  mat- 
ters it  would  lead  to  a  great  improvement  in  the  sanitation  of  their 
dwellings  and  of  their  surroundings.  Idealizing  this,  some  of  the 
states  have  made  a  commendable  beginninq:  bv  the  publication  of 
occasional   bulletins   on    such    matters,   but   the    appropriations    of 

(391) 


148  The  Annals  of  the  American  Academy 

money  for  these  purposes  are  so  small  that  the  bulletins  do  not 
cover  the  ground  and  are  not  regularly  distributed. 

The  Sick  are  Carriers  of  Disease 

Perhaps  one  of  the  most  vital  reasons  for  popular  education 
on  these  subjects  lies  in  the  discoveries  which  have  lately  been 
made  of  the  existence  of  chronic  cases  of  infectious  diseases  which 
were  formerly  thought  to  be  entirely  limited  to  cases  in  the  acute 
form.  It  is  now  known  that  typhoid  fever  is  not  entirely  limited 
to  those  persons  who  suflfer  from  acute  attacks,  but  that  it  may 
become  established  in  a  chronic  form  and  the  bacteria  remain  in 
the  system  of  some  persons  for  many  years.  The  records  show 
that  these  bacteria  have  been  carried  for  more  than  fifty  years  in 
persons  who  gave  no  external  appearance  of  having  the  disease. 
A  recent  estimate  by  one  investigator  shows  that  as  many  as  four 
per  cent  of  the  ]>ersons  having  typhoid  fever  continue  to  carry  the 
bacteria  in  their  bodies  and  to  discharge  them  for  as  long  as  three 
years  after  they  have  apparently  recovered  from  the  disease.  One 
investigator  estimates  that  there  are  at  the  present  time  eighteen 
thousand  persons  in  apparently  good  health  in  the  United  States 
who  carry  the  germs  of  typhoid  fever  and  who  must  be  looked  upon 
as  a  threat  against  the  health  of  the  communities  in  which  they  live. 
At  any  time  such  a  person  may  be  the  cause  of  a  typhoid  outbreak. 
Tuberculosis  has  of  course  for  many  years  been  recognized  as  a 
chronic  disease  and  the  persons  afflicted  with  it  as  sources  of  infec- 
tion. More  recently  diphtheria  has  been  shown  to  exist  in  a 
chronic  condition,  and  it  is  beginning  to  be  accepted  that  in  this  way 
the  disease  is  carried  on  from  year  to  year.  There  are  rumors  that 
scarlet  fever  is  also  a  disease  which  exists  in  a  chronic  form  in  some 
persons,  and  that  it  may  be  passed  on  in  this  manner.  Possibly  in 
time  other  infectious  diseases  will  come  into  the  same  category. 
These  things  being  so  the  matter  of  personal  hygiene  on  the  part  of 
those  who  are  afflicted  with  these  infections  in  a  chronic  form  is 
positively  necessary  to  protect  their  neighbors  from  contracting  the 
disease  from  them.  On  the  other  hand,  the  personal  care  exercised 
by  the  individual  in  his  daily  conduct  toward  his  neighbors,  the 
food  he  eats,  and  the  liquids  he  drinks  are  the  only  means  at  his 
command  for  protecting  himself  against  these  chronic  carriers  of 
disease.     It  is  obvious  that  public  education  on  these  matters  at 

(392) 


Sanitation  in  Rural  Communities  149 

the  present  time  is  the  best  form  of  defense.  The  majority  ot 
persons  carrying  these  diseases  are  undiscovered.  The  more  closely 
therefore  that  one  adheres  to  strict  personal  cleanliness  and  avoids 
contact  with  one's  neighbor  is  one  likely  to  escape  accidental  trans- 
fer of  these  diseases. 

It  is  to  be  hoped  that  public  sentiment  on  matters  of  sanitation 
and  of  general  health  will  in  the  course  of  time  reach  the  same 
degree  of  interest  that  is  displayed  in  the  study  of  agriculture.  It 
does  not  seem  unfair  to  suggest  to  the  public  authorities  that  at 
least  as  much  money  should  be  spent  in  instructing  the  dwellers 
in  rural  communities  how  to  raise  their  own  children  and  to  pro- 
tect themselves  against  infectious  disease,  as  is  now  expended  in 
informing  them  how  to  raise  pigs  and  how  to  breed  cattle  and 
horses. 


(393) 


TROPICAL  DISEASES  AND  HEALTH  IN  THE  UNITED" 

STATES 


By  John  M.  Swan,  M.D., 

Medical  Director  of  The  Glen  Springs;  Secretaixy  of  the  American  Society 
of  Tropical  Medicine,  Watkins,  N.  Y. 


Introduction. — Many  of  the  problems  that  demand  solution  at 
the  hands  of  the  sociologist  concern  the  parasites  that  infest  the 
body  politic,  impairing  its  efficiency.  The  physician,  on  the 
other  hand,  particularly  he  who  is  engaged  in  the  solution  of  the 
problems  of  sanitation,  is  concerned  to  a  very  large  extent  v/ith 
the  study  of  the  parasites  that  infest  the  physical  body,  producing 
sickness  and  death. 

Since  the  development  of  modern  bacteriology,  which  saw  its 
beginning  in  about  1870,  the  knowledge  of  the  causes  of  the  acute 
infectious  diseases  of  man  has  had  an  interesting  and  rapid  evolu- 
tion. Following  naturally  the  discovery  of  the  exciting  causes  of 
various  diseases,  the  methods  of  preventing  the  development  of  those 
maladies  were  rapidly  worked  out.  But  it  was  soon  found  that 
some  affections  that  acted  like  other  acute  infectious  diseases  of 
known  etiology  could  not  be  associated  with  a  discoverable  bac- 
terium in  the  relation  of  cause  and  efifect.  The  discovery  by 
Laveran,  in  1880,  of  the  Plasmodium  malarise  and  the  demonstra- 
tion of  its  animal  characteristics  led  to  fresh  investigations.  These 
studies,  in  turn,  showed  that  some  of  the  acute  infections  were 
due  to  animal  parasites.  The  understanding  of  the  life  history  of 
these  organisms,  however,  has  proved  to  be  a  much  more  com- 
plicated matter  than  the  description  of  the  biological  characters 
of  the  vegetable  parasites. 

It  has  been  found  that  many  of  the  animal  parasites  of  which 
man  is  the  host  cannot  be  transmitted  from  one  individual  directly 
to  another.  The  parasitic  organism  requires  a  developmental  period 
in  an  intermediate  host  before  it  can  be  inoculated  into  another 
individual  there  to  develop  and  produce  disease.  The  parasitic 
form   which  infects  the   intermediate  host   is  usually  different  in 

(394) 


Tropical  Diseases  and  Health  in  United  States  151 

morphology  from  that  which  produces  the  disease  in  man.  The 
intermediate  hosts  are  usually  insects  or  some  other  animal  low  in 
the  zoological  scale.  These  low  animal  forms  require  warmth, 
moisture,  and  oxygen  for  their  development.  These  three  requisites 
are  also  necessary  for  the  development  of  the  parasites  themselves, 
as  well  as  for  the  growth  of  the  vegetable  parasites,  bacteria,  that 
produce  disease. 

All  of  the  lower  forms  of  life,  whether  animal  or  vegetable, 
flourish  best  in  warm,  moist  climates,  so  that  we  find  some  regions 
of  the  earth  more  unhealthy  than  other  regions,  on  account  of  the 
greater  amount  of  moisture  and  heat  with  the  resulting  profuse 
growth  of  the  lowest  forms  of  life.  In  addition  to  heat  and  moisture, 
the  lower  forms  of  life  require  a  certain  amount  of  food  in  the 
nature  of  decomposing  animal  and  vegetable  material.  This  is 
found  in  abundance  in  hot,  moist  climates,  particularly  when  no 
effort  is  made  to  prevent  the  accumulation  of  such  decomposing 
masses.  Furthermore,  a  hot,  moist  climate  is  debilitating  to  the 
human  organism,  so  that  initiative  and  energy  are  lacking  and  a 
disposition  is  developed  to  let  things  go  as  nature  apparently  means 
that  they  shall  go :  the  si)irit  to  improve  conditions  is  lacking.  Con- 
sequently, we  observe  the  establishment  of  a  vicious  circle ;  the 
native  is  lacking  in  energy ;  he  permits  masses  of  decomposing 
animal  and  vegetable  matter  to  accumulate  in  the  vicinity  of  his 
dwelling;  this  breeds  the  lower  forms  of  life  which  are  able  to 
develop  the  parasites  that  produce  disease ;  these  parasites  infect 
the  dweller  in  their  neighborhood.  Those  inhabitants  that  escape 
death  are  still  further  reduced  in  vitality  and  their  efficiency  is  still 
further  impaired.  Furthermore,  they  are  carriers  of  disease-pro- 
ducing parasites  which  increase  in  number,  until  finally,  the  neigh- 
borhood acquires  an  unenviable  reputation  as  a  pest  hole. 

Climate. — The  climates  of  the  world  are  divided  by  Dr.  C.  Hart 
Merriam  (National  Geographic  Magazine,  1894,  Vol.  VI)  into  the 
Tropical  Zone,  the  Lower  Austral  Zone,  the  Upper  Austral  Zone,  the 
Transitional  Zone,  and  the  Boreal  Zone,  according  to  the  total 
amount  of  heat  present  during  the  year.  In  the  Tropical  Zone 
there  is  26,000°  F.  of  heat  during  a  year,  the  hottest  period  showing 
a  maximum  temperature  of  78.8°  or  over.  In  the  Lower  Austral 
Zone  the  total  heat  amounts  to  18.000°  F.  with  the  hottest  period 
above  78.8°.    In  the  Upper  Austral  Zone  the  total  heat  is  11,500°  F., 

(395) 


152  The  Annals  of  the  American  Academy 

with  the  hottest  period  below  78.8°  F.  In  the  Transitional  Zone  the 
total  heat  is  10,000°  F.,  with  the  hottest  period  below  71.6°  F.  In 
the  Boreal  Zone  the  total  heat  for  the  year  is  below  10,000°  F.  and 
the  hottest  period  is  below  64.4°  F. 

The  Tropical  Zone  extends  from  the  Tropic  of  Cancer,  23°  30' 
north  of  the  equator,  to  the  Tropic  of  Capricon,  23°  30'  south  of 
the  equator.  But  north  of  the  Tropic  of  Cancer  and  south  of  the 
Tropic  of  Capricorn  there  is  a  belt,  the  Lower  Austral  Zone,  in 
which  for  a  considerable  part  of  the  year  the  climatic  conditions 
are  similar  to  those  in  the  Tropical  Zone.  In  the  United  States, 
this  zone  includes  all  of  the  Southern  and  Western  states  below  the 
thirty-fifth  parallel  of  north  latitude:  South  Carolina,  Georgia, 
Florida,  Alabama,  Mississippi,  Louisiana,  and  Texas,  and  parts 
of  North  Carolina,  Arkansas,  Indian  Territory,  Oklahoma,  New 
Mexico,  Arizona,  and  California.  It  is  even  probable  that  this  line 
could  be  pushed  as  far  north  as  the  fortieth  parallel.  In  1909,  for 
example,  Philadelphia  had  a  total  amount  of  heat  of  20,153°  F., 
this  is  over  18,000°  F.  During  the  hottest  period  the  thermometer 
registered  above  78.8°  F.  Even  subtracting  the  558  degrees  excess 
temperature  over  the  normal  temperature  for  Philadelphia  in  1909 
the  total  heat  would  be  19,593  degrees,  enough  to  include  Philadel- 
phia, which  is  39°  57'  north  latitude,  in  the  Lower  Austral  Zone. 
In  1910  the  total  amount  of  heat  was  19,861°  F.,  with  the  hottest 
period  above  78.8°  F.  Similar  studies  would  show  that  many  places 
in  the  United  States  possess  the  necessary  amount  of  temperature 
for  their  inclusion  in  this  zone. 

Requisites  for  the  Development  of  a  Disease  from  the  Tropics. 
In  order,  however,  that  any  disease  shall  develop  in  a  given 
region  of  the  world,  three  essentials,  in  addition  to  a  proper  cli- 
matic condition,  must  be  present:  the  cause  of  the  disease,  the 
proper  transmitting  agent,  and  susceptible  individuals.  Climatic 
features  may  be  suitable,  the  cause  of  the  disease  may  be  present, 
susceptible  individuals  may  reside  in  the  district ;  but  if  the  trans- 
mitting agent  is  absent  the  disease  will  not  develop.  If  now  the 
transmitting  agent  is  suddenly  introduced  into  that  locality  an 
epidemic  of  the  disease  will  result. 

On  the  other  hand,  the  transmitting  agent  may  be  present  and 
susceptible  individuals  may  reside  in  a  locality ;  but  if  individuals 
harboring  the  parasites  be  not  present,   the  disease  will  not  be 

(396) 


Tropical  Diseases  and  Health  in  United  States  153 

found.  If  now  human  hosts  of  the  parasite  come  to  the  region  in 
question  bringing  the  parasites  with  them  an  epidemic  will  follow. 

Relations  of  the  United  States  with  the  Tropics. — The  Anglo- 
Saxon  race  has  had  intimate  relations  with  the  tropics  for  over 
three  hundred  years.  In  1579  Thomas  Stevens  sailed  from  Lisbon 
to  Goa  in  India.  So  far  as  is  known  he  was  the  first  Englishman 
to  visit  that  great  empire.  In  1583  three  London  merchants  started 
overland  for  India.  This  enterprise  was  followed  by  the  endeavor 
of  three  ships  to  make  the  journey  around  the  Cape  of  Good  Hope 
in  1 59 1.  The  fabulous  wealth  reported  to  be  in  existence  led  to 
the  formation  of  the  British  East  India  Company,  which  was  char- 
tered in  1600,  and  sent  out  its  first  expedition  in  1601.  Ever  since 
then  England  has  had  intimate  relations  with  the  tropics  and  has 
known  at  first  hand  of  the  ravages  of  its  diseases.  That  part  of 
the  Anglo-Saxon  race  which  resides  in  the  Western  Hemisphere 
has  had  a  merely  casual  acquaintance  with  the  tropics  until  the 
occurrence  of  the  Spanish-American  War,  in  1898.  The  acquisi- 
tion of  the  Philippine  Islands,  Puerto  Rico,  and  Guam,  followed 
by  our  intimate  relations  with  Cuba  and  the  undertaking  of  the 
Panama  Canal  has  brought  the  problems  of  tropical  pathology  and 
tropical  hygiene  strongly  to  our  attention.  We  suddenly  realize 
that  many  of  our  home  ports  are  within  the  limits  of  the  Lower 
Austral  Zone:  Galveston,  28°  18'  N. ;  New  Orleans,  29°  57'  N. ; 
Mobile,  30°  45'  N. ;  Jacksonville,  30°  45'  N. ;  Savannah,  32°  4'  N., 
and  that  the  United  States-Mexican  border^  extends  for  a  varying 
distance  north  and  south  of  the  thirtieth  parallel  of  north  lati- 
tude. We  then  find  that  other  of  our  ports  have  a  total  degree  of 
heat  that  would  be  suitable,  for  a  portion  of  the  year  at  least,  for 
the  development  of  diseases  supposed  to  be  peculiar  to  the  tropics, 
provided  all  the  essentials  were  present. 

We  find  424,313  immigrants  landing  on  our  shores  from  tropical 
and  subtropical  countries  in  1907,  and  224,930  immigrants  from  the 
same  regions  in  1908.  Our  soldiers,  our  sailors,  our  missionaries 
and  our  business  men  are  visiting  the  tropics  in  greater  numbers 
with  the  advancing  years.  We  further  find  that  at  home  we  have 
had  for  many  years  a  disease  common  in  the  tropics,  uncinariasis, 
or  hookworm  disease,  probably  imported  from  Africa  with  slaves. 
Tropical  medicine,  consequently,  is  a  matter  of  intimate  concern 
to  the  health  authorities  of  our  country,  and  not  a  mere  academic 

(397) 


154  The  Annals  of  the  American  Academy 

question.  The  immigrant  and  the  homecoming  citizen  are  important 
enough  to  require  consideration  in  this  respect,  if  we  had  never 
had  an  epidemic  of  yellow  fever,  of  plague,  or  of  cholera  in  our 
home  territory.  The  prevention  of  an  epidemic  of  imported  disease, 
however,  is  a  comparatively  easy  matter  when  the  cause  is  known, 
and,  at  the  hands  of  the  United  States  Public  Health  and  Marine- 
Hospital  Service  the  introduction  of  epidemics  has  been  and  will 
be  prevented  so  far  as  foreknowledge,  foresight,  and  purisdiction 
can  accomplish  the  result. 

The  Essential  Feature  of  the  Prevention  of  Tropical  Disease. 
— The  one  essential  feature  of  prevention  of  tropical  diseases  is  the 
cleanliness  of  our  seaports,  the  cleanliness  of  our  inhabitants,  the 
cleanliness  of  our  houses.  By  cleanliness  is  meant  the  drainage  of 
mosquito  breeding  marshes  and  streams,  the  prevention  of  the  devel- 
opment of  fiies,  and  the  destruction  of  rats  and  mice,  as  well  as 
the  washing  of  bodies,  the  fumigation  of  houses  and  vessels,  the 
sweeping  of  streets,  the  proper  disposition  of  sewage  and  garbage, 
and  the  inspection  of  food  products. 

The  Tropical  Diseases. — The  following  list  of  disorders  may 
be  looked  upon  as  including  the  diseases  indigenous  to  tropical  and 
subtropical  countries  which  can  be  transmitted  to  temperate  climates, 
upper  austral  and  transitional,  provided  the  requisite  conditions 
of  heat,  moisture,  intermediate  hosts,  parasites,  and  susceptible 
population  are  present  in  the  given  locality. 

A.  Disease  due  to  protozoan  (one-celled)  parasites: 

I,  malaria;  2,  hemoglobinuric  fever;  3,  amebiasis;  4,  try- 
panosomiasis; 5,  kala  azar;  6,  spirochetosis:  (0),  re- 
lapsing fever;  {h) ,  Rocky  Mountain  fever;  (c), 
tabardillo. 

B.  Diseases  due  to  metazoan  (many-celled)  parasites: 

I,  trematode  infection;  2,  cestode  infection;  3  nematode 
infection. 

C.  Diseases  due  to  bacteria: 

I,  plague;  2,  cholera;  3,  dysentery;  4,  Malta  fever;  5, 
leprosy. 

D.  Diseases  of  unknown  etiology: 

I,  yellow  fever;  2,  dengue;  3,  beriberi;  4,  pellagra. 
(398) 


Tropical  Diseases  and  Health  in  United  States  155 

Malaria  is  a  disease  indigenous  to  the  tropics  and  to  subtropical 
countries.  It  is  caused  by  a  genus  of  protozoan  parasites,  known 
as  Plasmodium,  of  which  there  are  at  least  three,  and,  according  to 
some  writers,  more  species.  The  parasite  is  known  to  undergo  a 
cycle  of  development  within  its  human  host,  which  perpetuates 
the  disease  in  the  individual.  While  the  various  steps  in  this  cycle 
are  taking  place  regularly,  a  second  form  of  development  of  the 
parasite  takes  place,  which  results  in  the  production  of  forms  that 
produce  no  symptoms  in  the  human  host;  but  which  are  capable 
of  infecting  the  intermediate  host.  The  intermediate  host  of  the 
Plasmodium  is  the  female  mosquito  of  the  subfamily  Anophelinae. 
Not  all  species  of  anopheles  mosquitoes  can  become  infected  from 
the  human  host,  but  at  least  seven  have  been  shown  by  actual  experi- 
ment to  be  the  efficient  agents  for  the  transmission  of  the  disease. 
Manson*,  however,  gives  a  list  of  thirty-two  species  from  various 
parts  of  the  world  which  are  known  or  suspected  to  be  efficient 
hosts  of  the  Plasmodium.  After  the  parasite  has  passed  through 
its  developmental  stage  in  the  body  of  the  mosquito,  forms  result 
that  can  be  inoculated  into  a  susceptible  human  subject  by  the  bite 
of  the  insect,  and  so  the  disease  is  spread.  No  other  method  of 
transmission  from  man  to  man  is  known. 

Mosquitoes  always  breed  in  water.  Some  species  prefer  clean, 
slowly  running  water;  others  prefer  stagnant  water;  still  others 
breed  in  collections  of  water  in  artificial  containers.  The  members 
of  the  subfamily  Anophelinae  prefer,  as  a  rule,  the  clean,  slowly 
running  water  found  at  the  edges  of  streams  and  in  marshes  in 
which  there  is  some  curretjt. 

The  amount  of  sickness  due  to  malaria  in  a  malarial  country 
is  incalculable,  Woldert  (Texas  Medical  News,  April,  1908)  esti- 
mates that  malaria  causes  the  loss  of  an  equivalent  of  over  five 
million  dollars  a  year  in  the  State  of  Texas  alone.  The  most  effi- 
cient way  to  prevent  the  sickness  and  death  due  to  this  disease  is 
the  destruction  of  the  breeding  places  of  the  intermediate  host  of 
the  parasite.  Marshes  should  be  drained  or  filled  in.  Streams 
should  be  cleaned  of  the  growth  of  grasses,  flags,  and  sedges  which 
are  found  near  the  banks,  delaying  the  currents,  and  providing  by 
their  interlacing  roots  safe  retreats  for  the  mosquito  larva  from 
their  natural  enemies.  Artificial  collections  of  water  should  be 
destroyed  or  efficiently  screened  so  that  the  adult  female  cannot 

(399) 


156  The  Annals  of  the  American  Academy 

gain  access  to  them  for  the  purpose  of  depositing  her  eggs.  All 
money  spent  by  the  state  in  this  work  is  well  invested.  The  return 
is  seen  in  the  increased  efficiency  of  the  individual,  in  the  lowered 
death  rate  and  sick  rate,  and,  in  the  case  of  drained  marshes,  in  the 
increase  in  the  area  of  arable  land.    , 

A  district  in  which  there  is  no  malaria  may  owe  its  freedom 
to  the  absence  of  the  proper  malaria  carrying  mosquito,  to  the 
absence  of  individuals  harboring  that  form  of  the  malarial  para- 
site in  their  blood  which  can  infect  the  mosquito,  or  to  both.  If 
the  proper  mosquitoes  exist  in  a  given  neighborhood,  but  no  infected 
individuals  are  present,  no  malaria  will  be  found ;  but  if  human 
hosts,  apparently  in  perfect  health,  with  the  suitable  form  of  the 
malarial  parasite  in  the  blood  are  brought  to  the  region,  an  epidemic 
of  malaria  will  result.  For  example,  if  a  rural  district  contains 
swamps  or  choked  streams  in  which  anopheles  mosquitoes  are  breed- 
ing, and  a  gang  of  Italian  or  West  Indian  laborers,  many  of  whom 
harbor  malarial  parasites,  are  imported  for  the  purpose  of  some 
public  work  such  as  road  building  or  canal  excavating,  an  epidemic 
of  malaria  will  follow. 

On  the  other  hand,  a  malarial  district  may  be  rendered  almost 
nonmalarial  by  destroying  the  breeding  places  of  the  mosquitoes. 
The  active  work  of  the  Department  of  Sanitation  of  the  Isthmian 
Canal  Commission  in  searcliing  for  and  destroying  the  breeding 
places  of  mosquitoes  in  the  Canal  Zone,  and  screening  the  quarters 
of  the  employees,  has  resulted  in  the  reduction  of  the  morbidity 
from  malaria  from  821  per  1,000,  in  1906,  to  282  per  1,000  in  1908, 
and. 215  per  1,000  in  1909.  The  mortality  was  reduced  from  8.77 
per  1,000  in  1906,  to  1.34  per  1,000  in  1908,  and  i.io  per  1,000  in 
1909.  This  result  can  be  paralleled  in  any  American  community 
by  similar  methods  with  a  relatively  small  outlay  of  money. 

The  Italian  method  of  furnishing  quinine  to  the  inhabitants  for 
prophylactic  purposes  is  not  nearly  so  efficient ;  nor  is  a  method 
which  relies  on  screening  the  dwellings  of  the  inhabitants  without 
a  campaign  for  the  destruction  of  the  mosquitoes  and  their  breeding 
places. 

Hemoglobinuric  fever,  or  blackwater  fever,  is  believed  by 
many  writers  to  be  dependent  upon  previous  malaria.  If  this  be 
so,  the  control  of  the  latter  will  be  attended  by  the  disappearance 
of  the  former  disease.     There  are  students  of  tropical  problems, 

(400) 


Tropical  Diseases  and  Health  in  United  States  157 

however,  who  believe  that  hemoglobinuric  fever  is  an  independent 
disease.  If  this  be  true  it  should  be  placed  among  the  diseases  of 
unknown  etiology.  Hemoglobinuric  fever  is  present  in  the  Philip- 
pine Islands,  in  the  West  Indies,  in  Central  and  South  America,  in 
the  Canal  Zone,  in  Texas,  and  in  Arkansas,  and  probably  in  other 
parts  of  the  lower  austral  zone  of  the  United  States.  So  far  as 
we  know  at  present  its  deleterious  influence  upon  the  public  health 
is  not  great  and  no  alarm  need  be  felt  for  an  extensive  propagation 
of  cases. 

Amebiasis  is  a  disease  due  to  a  protozoan  parasite,  Entameba 
histolytica,  which  attacks  the  large  intestine  of  man  and  of  the 
lower  animals.  The  infection  manifests  itself  by  attacks  of  dysen- 
tery, and  in  many  of  the  cases,  as  high  as  33  per  cent  in  some 
instances,  it  is  followed  by  abscess  of  the  liver.  The  parasite  is 
apparently  transmitted  from  man  to  man  by  potable  water.  It  is 
possible  that  it  may  be  transmitted  by  green  vegetables,  in  localities 
where  human  feces  is  used  as  a  fertilizer,  as  is  the  custom  in  China 
and  other  Eastern  countries.  Its  spread  may  be  stopped  by  boiling 
the  drinking  water,  by  the  prohibition  of  the  use  of  human  excre- 
ment as  a  fertilizer,  and  by  the  prohibition  of  indiscriminate  defeca- 
tion into  streams  or  other  sources  of  water  supply  for  towns,  vil- 
lages, or  isolated  farm  houses. 

Amebiasis  is  prevalent  in  the  Canal  Zone,  certain  of  the  West 
India  Islands,  some  of  the  Southern  states,  for  example,  Louis- 
iana, Puerto  Rico,  and  the  Philippine  Islands.  Individuals  with 
intestinal  trouble  returning  from  these  countries  should  be  carefully 
studied  for  the  detection  of  these  parasites. 

Trypanosomiasis  is  a  disease  due  to  a  protozoan  parasite, 
Trypanosoma  gambiense.  It  is  at  first  a  febrile  complaint  which 
bears  some  resemblance  in  its  clinical  manifestations  to  malaria; 
but  in  its  last  stages  it  is  accompanied  by  a  marked  degree  of 
lethargy  and  is  commonly  known  as  sleeping  sickness.  The  parasite 
is  transmitted  from  man  to  man  by  a  dipterous  insect ;  the  Tsetse 
fly,  Glossina  palpalis.  The  disease  is  confined  to  the  valley  of  the 
Congo  River,  the  shores  of  Victoria  Nyanza,  and  other  parts  of 
tropical  Africa.  So  far  as  is  known  Glossina  pa4palis  does  not 
breed  on  the  American  Continent,  consequently  no  harm  is  to  be 
apprehended  from  this  disease  in  the  United  States,  even  if  an 
infected  individual  should  land  upon  our  shores.     If  Glossina  pal- 

(401) 


158  The  Annals  of  the  American  Academy 

palis  can  be  bred  in  our  own  lower  austral  region,  the  United  States 
Public  Health  and  Marine-Hospital  Service  will  have  to  institute 
active  fumigation  measures  on  all  ships  coming  from  African  ports 
to  our  Gulf  and  South  Atlantic  ports  to  prevent  the  domestication 
of  the  fly. 

Kala  Azar  is  a  disease  due  to  a  protozoan  parasite,  Leishmania 
Donovani.  It  is  found  in  Assam,  Madras  and  Bengal.  The  method 
of  transmission  of  the  parasite  is  not  known,  and  no  danger  is  to 
be  apprehended  from  this  disease.  Dr.  S.  T.  Darling,  however, 
has  observed  a  few  cases  in  the  Canal  Zone  similar  to  Kala  Azar, 
and  has  found  a  parasite  of  similar  appearance  in  the  organs  of  the 
patients  at  necropsy.  This  parasite  has  been  called  Histoplasma 
capsulatum.  The  possibility  of  serious  danger  to  the  public  health 
from  such  a  source  is  remote. 

The  best  known  example  of  spirochetosis  is  the  European 
relapsing  fever,  due  to  an  organism  known  as  Spirocheta  recurrens. 
A  few  imported  cases  have  been  seen  in  this  country  and  small 
epidemics  have  been  recorded  in  New  York  and  in  Philadelphia  in 
past  years.  The  parasite  is  supposed  to  be  transmitted  by  the  bed- 
bug or  the  body  louse.  No  extensive  epidemic  of  this  disease  has 
been  observed  in  this  country  and  its  further  prevention  will  be 
accomplished  by  isolating  imported  cases  and  by  the  disinfection 
of  the  belongings  of  the  patients  for  the  destruction  of  any  vermin 
that  they  may  harbor. 

In  the  Bitter  Root  Valley  of  Wyoming,  and  in  some  other  parts 
of  our  Rocky  Mountain  region  there  is  an  epidemic  disease,  known 
as  Rocky  Mountain  fever,  which  is  known  to  be  transmitted  by 
the  bites  of  certain  ticks,  Dermacentor  occidentalis.  It  is  probable 
that  this  is  a  spirochetosis. 

The  disease  endemic  in  Mexico  known  as  tabardillo,  which 
caused  the  death  of  the  investigator  who  proved  the  transmission 
of  Rocky  Mountain  fever  by  the  bites  of  infected  ticks,  Dr.  H.  T. 
Ricketts,  is  in  all  probability  of  the  same  nature.  The  public  health 
authorities  of  the  states  forming  the  United  States-Mexican  border. 
Texas,  Arizona,  New  Mexico  and  California,  will  have  to  meet 
the  problem  of  the  prevention  of  the  importation  of  this  infection 
into  our  domain  with  the  increased  cammunication  across  the 
border. 

The  disease  caused  by  metazoan  parasites  are,  as  a  rule,  intes- 

(402) 


Tropical  Diseases  and  Health  in  United  States  159 

tinal  disturbances  due  to  the  presence  of  the  parasites  in  the  alimen- 
tary tract.  There  are  one  or  two  exceptions  to  this  rule,  notably 
the  disease  known  as  schistosomiasis,  in  which  the  parasites  and 
their  eggs  are  found  in  the  blood  vessels  of  the  gastro-intestinal 
canal  or  of  the  genito-urinary  organs,  and  the  disease  known  as 
filariasis,  in  which  the  parasites  are  found  in  the  lymphodes  or  the 
connective  tissue  in  the  various  parts  of  the  body.  In  filariasis  the 
embryos  are  found  in  the  circulating  blood. 

Many  of  these  parasites  gain  entrance  to  the  human  body  with 
food  or  drink,  others  require  development  up  to  a  certain  stage  in 
intermediary  hosts,  still  others  gain  entrance  to  the  human  body 
through  the  skin.  Much  work  remains  to  be  done  on  the  life  his- 
tories of  many  of  these  animals  before  definite  knowledge  of  the 
manner  of  infection  is  to  be  had. 

The  trematodes  are  low  forms  of  the  natural  order  Vermes. 
With  one  exception  they  are  hermaphroditic  organisms  which  infect 
the  various  parts  of  the  gastro-intestinal  tract.  One  variety,  which 
is  indigenous  to  the  Philippine  Islands  and  other  far  Eastern 
countries,  is  found  in  the  lungs.  The  parasites  are  not  known 
to  be  indigenous  to  any  part  of  the  United  States  although  it  is  not 
beyond  the  range  of  possibility  that  they  may  be  represented  in 
our  home  territory.  However,  climatic  conditions  are  such  in  our 
lower  austral  zone  that,  provided  suitable  intermediary  hosts  are 
present,  they  may  become  established  in  this  country.  So  far  as 
we  know,  cleanliness  in  personal  habits,  care  in  the  preparation 
of  food,  and  abstention  from  eating  uncooked  fruit  and  vegetables 
are  all  that  is  necessary  to  prevent  the  spread  of  such  infections. 

Schistosomiasis  is  the  disease  produced  by  a  trematode  para- 
site, in  which  the  male  and  female  generative  organs  are  contained 
in  separate  bodies.  The  disease  is  also  known  as  bilharziasis.  It 
is  common  in  Egypt  and  in  some  other  parts  of  Africa,  and  in  Asia, 
A  form  of  the  disease  has  been  met  with  in  the  West  Indies  and 
in  some  parts  of  Central  and  South  America.  The  symptoms 
depend  upon  the  location  of  the  parasites  and  their  ova.  Some- 
times an  inflammation  of  the  bladder  results;  in  other  cases  the 
symptoms  resemble  those  of  dysentery.  A  variety  of  this  infection  is 
met  with  in  China  and  Japan,  one  case  of  which  has  been  imported 
into  this  country. 

The  cestodes  are  the  tapeworms.    Infection  with  these  parasites 

(403) 


i6o  The  Annals  of  the  American  Academy 

is  by  no  means  confined  to  the  tropics  or  to  subtropical  countries; 
but  in  both  these  regions  cestode  infection  is  more  common  than 
in  temperate  climates.  Nearly  all  of  these  parasites  depend  for 
their  development  in  man  upon  the  eating  of  insufficiently  cooked 
meat.  The  inspection  of  our  abattoirs  by  the  officials  of  the  United 
States  Department  of  Agriculture  prevents  the  marketing  of  infected 
meat,  and  is  a  public  health  measure  of  the  first  order.  The  proper 
cooking  of  meat  is  further  responsible  for  the  rarity  of  the  occur- 
rence of  these  worms  in  Americans. 

The  nematodes  are  the  round  worms.  Infection  with  one  of 
these  is  fairly  common  even  among  the  children  of  the  better  class. 
Infection  with  the  hookworm,  Necator  americanus,  has  been  shown 
within  the  past  ten  years  to  be  very  common  in  the  Southern  states. 
Trichiniasis,  infection  with  Trichina  spiralis,  is  seen  in  rare  cases. 
Filarial  infections  have  been  reported  in  our  home  territory.  Pre- 
vention of  these  infections  varies  with  the  individual  parasite. 

Ascaris  lumbricoides  infection  is  to  be  prevented  by  teaching 
children  to  be  careful  of  the  things  which  they  put  into  their  mouths. 
We  do  not  know  the  life  history  of  this  parasite,  but  infection 
appears  to  be  the  result  of  taking  the  embryos  or  the  ova  into  the 
digestive  tract. 

Hookworm  disease,  uncinariasis,  is  a  serious  problem  in  our 
Southern  states.  The  embryos  develop  in  moist,  sandy  soil,  and 
gain  entrance  to  the  body  through  the  skin.  The  wet  sand  adheres 
to  the  skin  of  the  legs  and  feet,  and  the  embryos  burrow  into  the 
underlying  tissues  and  finally  reach  the  intestine  by  a  circuitous 
route.  The  disease  has  long  been  known  in  Egypt  and  other  parts 
of  the  tropics  of  the  Eastern  Hemisphere  as  anchylostomiasis.  It 
was  a  serious  public  health  problem  during  the  construction  of  the 
St.  Gothard  Tunnel,  in  1880.  Our  army  medical  men  found  it 
in  Puerto  Rico,  and  subsequently  the  parasites  were  discovered 
in  the  South,  Its  presence  results  in  a  severe  anemia  which  may 
be  fatal.  The  prevention  of  the  extension  of  the  disease  can  be 
accomplished  by  the  prohibition  of  soil  pollution  and  by  educating 
the  people  to  wear  shoes.  In  many  localities  the  inhabitants  are 
too  poor  to  buy  shoes.  In  such  circumstances  prevention  of  indis- 
criminate soil  pollution  is  first  in  order.  The  amelioration  of  pov- 
erty, on  the  other  hand,  so  that  each  individual  can  obtain  enough 

(404) 


Tropical  Diseases  and  Health  in  United  States  i6i 

compensation  for  his  work  to  be  able  to  buy  shoes  for  his  family 
is  a  question  for  the  political  economist  and  the  tariff  commission. 

It  has  been  found  in  Puerto  Rico  that  in  cases  of  certain  ladies 
of  the  better  class  who  harbored  Necator  americanus,  the  infection 
had  occurred  through  the  skin  of  the  hands  from  working  in  flower 
gardens,  the  soil  of  which  had  been  fertilized  by  human  feces.  It 
has  also  been  suggested  that  uncinariasis  was  one  of  the  causes  of 
the  high  morbidity  and  mortality  among  the  Union  prisoners  in 
Confederate  prisons  from  1861  to  1865,  particularly  in  Andersonyille. 

The  Rockefeller  commission  will  undoubtedly  succeed  in  ban- 
ishing this  infection  from  our  Southern  States.  It  must,  however, 
prosecute  a  long  campaign  of  education  before  it  can  improve  the 
sanitary  conditions  in  the  rural  districts  and  inculcate  new  habits 
of  personal  hygiene  in  the  inhabitants. 

In  filariasis  the  adult  parasite  inhabits  the  lymphnodes  and  the 
connective  tissues.  The  embryos  circulate  in  the  peripheral  blood. 
The  presence  of  these  parasites  excites  a  train  of  diseases,  the  best 
known  of  which  is  elephantiasis.  The  disease  is  present  in  certain 
of  the  West  India  Islands.  The  embryos  are  taken  into  the  stomach 
of  a  female  mosquito  and  undergo  a  metamorphosis  in  the  thoracic 
muscle  of  the  insect.  After  the  change  in  the  embryos  is  completed, 
they  migrate  to  the  proboscis  of  the  mosquito  and  are  inoculated 
into  the  new  individual  by  the  bite  of  the  insect. 

Whatever  of  danger  there  may  be  in  the  importation  of  filariasis 
into  the  United  States  is  to  be  obviated  by  a  mosquito  campaign. 
In  this  infection  the  intermediate  host  is  not  only  the  mosquito 
of  the  subfamily  Anophelinae  but  also  certain  species  of  the  sub- 
family Culicinse.  The  culex  mosquito  will  breed  in  any  kind  of 
water,  some  species  developing  in  almost  pure  filth.  Consequently, 
it  is  not  only  necessary  to  drain  marshes  and  to  clean  out  streams, 
but  also  to  dispose  of  all  collections  of  still  or  stagnant  water;  the 
water  in  flowerpots  in  cemeteries,  in  discarded  tin  cans,  in  broken 
bottles,  drains,  cisterns,  etc.,  has  been  found  swarming  with  culex 
larvae.  The  collections  of  water  in  the  hollow  branches  and  the 
trunks  of  trees,  and  in  the  corollas  of  many  plants,  such  as  the 
pitcher  plant,  have  been  found  to  be  breeding  places  for  these 
insects.  There  is  no  danger  of  the  direct  transmission  of  filarial 
infection  from  man  to  man. 

Of  the  diseases  due  to  bacteria,  plague  is  the  one  of  most 

(405) 


i62  The  Annals  of  the  American  Academy 

interest  to  the  American  health  officer.  The  disease  is  due  to  an 
organism  known  as  Bacillus  pestis.  Through  the  work  of  the  Eng- 
lish Plague  Commission,  done  in  Bombay  and  its  environs,  it  has 
been  definitely  established  that  the  disease  is  originally  one  of  rats 
and  mice  and  that  it  is  carried  from  rat  to  rat  by  the  bites  of  infected 
fleas.  After  the  rat  population  of  a  city  has  been  reduced  by 
the  epizootic,  the  fleas,  no  longer  finding  sufficient  animal  food, 
turn  their  endeavors  to  and  become  temporary  ectoparasites  of 
man.  The  epidemic  then  spreads  from  man  to  man  by  the  bites 
of  infected  fleas.  In  a  few  cases,  about  one  per  cent  in  a  large  epi- 
demic, the  disease  exists  in  man  as  a  pneumonia  excited  by  the 
Bacillus  pestis,  and  this  form  of  the  infection  is  transmissible  from 
man  to  man  directly  by  infected  sputum,  which  is  disseminated  by 
coughing,  and  by  soiled  bed  linen  and  personal  linen. 

In  the  prevention  of  an  epidemic  of  plague,  the  destruction 
of  rats  and  mice,  is  the  important  sanitary  problem.  The  isolated 
patient  is  not  dangerous  provided  he  is  not  suffering  from  the 
pneumonic  form  of  the  disease.  Plague  has  been  present  in  San 
Francisco  twice  within  the  past  ten  years.  In  1900  the  business 
men  and  health  officials  of  San  Francisco  and  California  made  a 
serious  blunder  in  denying  the  existence  of  the  disease,  and,  by 
their  attitude,  causing  the  resignation,  of  an  officer  of  the  United 
States  Public  Health  and  Marine-Hospital  Service  who  was  emi- 
nently equipped  for  coping  with  the  situation.  As  a  result,  the 
disease  ran  for  a  period  of  two  or  three  years  with  occasional  cases 
reported,  and  the  rat  population  of  San  Francisco  became  gener- 
ally infected  so  that  in  1907  plague  again  appeared  in  that  city. 
This  time,  however,  profiting  by  the  former  error,  the  health  author- 
ities of  California  and  of  San  Francisco  summoned  the  federal 
authorities  to  their  aid  and,  by  placing  the  matter  entirely  in  the 
hands  of  the  latter,  had  the  satisfaction  of  seeing  the  epidemic 
stopped  in  eight  months  with  a  total  of  160  cases  and  78  deaths. 
Fifteen  cases  occurred  in  Oakland  and  Seattle  with  10  deaths. 
During  this  period  the  Public  Health  and  Marine-Hospital  men 
were  killing  10,000  rats  a  week,  about  three  per  cent  of  which  were 
found  infected  with  Bacillus  pestis.  The  officers  in  charge  of  the 
work  further  developed  the  fact  that  the  wood  squirrels  about  Oak- 
land were  infected  with  plague,  and  measures  have  been  taken  to 
destroy  these  rodents. 

(406) 


Tropical  Diseases  and  Health  in  United  States  163 

The  destruction  of  rats  in  our  seaports  is  a  problem  that  should 
at  once  receive  attention  from  the  proper  sanitary  authorities.  A 
ship  coming  from  a  plague  j)ort  with  infected  rats  in  its  hold 
should  be  so  moored  that  these  animals  cannot  get  ashore.  For 
this  purpose  rat  guards  have  been  devised  for  the  purpose  of  pre- 
venting the  rodents  from  leaving  the  vessel  at  night  by  way  of  the 
hawsers,  and  starting  an  epizootic  among  the  rats  on  land.  Once 
started  in  New  York  or  Philadelphia  these  cities  would  pass  through 
an  experience  similar  to  that  of  San  Francisco.  The  rat  population 
is  ready  to  hand,  the  rat  flea  is  ready  with  his  host,  and  the  climatic 
conditions  from  May  to  October  are  suitable. 

No  advantage  except  a  temporary  one,  is  ever  gained  by  deny- 
ing the  exisence  of  an  epidemic  in  any  city.  The  hiding  of  the 
facts  gives  a  chance  for  the  disease  to  gain  headway  and  to  result 
finally  in  a  greater  loss  to  business  and  a  more  appalling  loss  of 
life  than  though  the  disease  were  admitted  to  exist  from  the  begin- 
ning and  proper  prophylactic  measures  immediately  instituted. 

Cholera  is  due  to  the  Bacillus  cholerae.  It  is  a  water-borne  dis- 
ease, the  infected  individual  polluting  the  water  supply  by  improper 
disposition  of  his  feces.  Flies  are  sometimes  responsible  for  epi- 
demics by  first  alighting  on  objects  contaminated  with  the  bacilli 
and  then  alighting  upon  exposed  food  stuflfs.  It  is  hardly  to  be 
conceived  that  an  epidemic  of  this  disease  should  start  in  any  of 
our  American  cities.  The  quarantine  officers  are  constantly  on 
the  lookout  for  cases  of  intestinal  disturbance  in  immigrants  from 
parts  in  which  cholera  exists,  as  well  as  in  the  members  of  the 
crews  of  the  vessels. 

In  Mohammedan  countries  many  pilgrims  returning  from 
Mecca  bring  holy  water  with  them  from  the  Holy  City.  In  order 
to  give  all  the  faithful  an  opportunity  to  benefit  from  the  water, 
the  contents  of  the  bottle  are  emptied  into  the  well  or  other  source 
of  water  supply  of  the  village  to  which  the  pilgrim  belongs.  Since 
the  holy  water  "frequently  contains  cholera  bacilli,  an  epidemic 
results.  With  the  increasing  Mohammedan  population  of  the 
Pacific  coast  this  is  a  problem  that  may  confront  our  health  offi- 
cers in  the  future.  Infection  of  the  individual  is  to  be  prevented 
by  boiling  the  drinking  water,  by  abstaining  from  the  use  of 
uncooked  foods,  and  by  care  in  the  production  of  the  milk  supply. 
The  house  fly  should  not  be  neglected.     The  patient  is  not  dan- 

(407) 


164  The  Annals  of  the  American  Academy 

gerous  provided  his  intestinal  and  other  discharges  are  properly 
sterilized  before  being  consigned  to  the  cesspool  or  sewer.     Burn- 
ing is  the  most  efficacious  method  of  disposing  of  infected  human" 
feces. 

Dysentery,  except  the  amebic  form,  already  referred  to  under 
the  head  of  amebiasis,  is  due  to  Bacillus  dysenterise.  The  epidemics 
are  of  minor  import,  so  far  as  they  have  occurred  in  our  own  land. 
In  the  tropics  and  in  subtropical  countries,  where  the  climate 
is  depressing  and  where  the  poorer  classes  are  more  constantly 
underfed  and  overworked  than  with  us,  the  disease  often  assumes 
serious  proportions.  It  is  water-borne  and  requires  the  same  pre- 
ventive measures  that  apply  to  cholera.  The  fly  problem  is  impor- 
tant in  its  relation  to  this  infection. 

Malta  fever  is  caused  by  the  Micrococcus  meltensis.  Cases  of 
the  disease  are  found  in  the  Mediterranean  littoral  in  greatest 
numbers.  Cases  have  been  found  in  Cuba  and  Puerto  Rico,  Cen- 
tral and  South  America,  and  it  is  not  beyond  the  range  of  possi- 
bility that  cases  occur  along  the  United  States  shores  of  the  Gulf 
of  Mexico.  In  Malta,  the  disease  is  supposed  to  be  transmitted 
by  drinking  the  milk  of  infected  goats;  these  animals  supplying 
the  milk  for  the  inhabitants  of  the  island.  The  disease  is  not  very 
severe  and  the  death  rate  is  small,  about  three  per  cent.  It  is  respon- 
sible, however,  for  a  large  amount  of  invalidism.  The  problems 
to  be  solved  in  case  it  should  ever  be  found  in  our  country  are 
entirely  hypothetical. 

The  attitude  of  the  public  toward  leprosy  is  a  blot  upon  our 
civilization.  The  disease  is  caused  by  the  Bacillus  leprae.  It  is  not, 
strictly  speaking,  a  tropical  disease,  Norway  and  Iceland  being 
countries  in  which  it  is  indigenous.  It  is  transmitted  only  by  very 
intimate  personal  contact.  The  patient  is  not  a  danger  to  the 
community  in  which  he  dwells,  unless  it  be  proved  that  the  sus- 
picion, now  entertained,  that  the  organism  is  transmitted  by  the 
bites  of  infected  bedbugs  is  warranted.  Even  then  cleanliness  is 
the  answer  to  the  public  health  question  involved.  The  segrega- 
tion of  lepers  in  colonies  is  advisable  on  account  of  the  repulsive 
nature  of  the  deformities  seen  in  the  advanced  cases;  but  not 
because  there  is  any  fear  of  an  epidemic. 

Leprosy  is  endemic  in  many  Central  and  South  American 
States.     There  is  a  leper  colony  in  Louisiana.     It  is  common  in 

(408) 


Tropical  Diseases  and  Health  in  United  States  165 

the  Hawaiian  Islands,  in  China,  in  Japan,  and  in  the  Philippine 
Islands.  The  treatment  of  the  unfortunate  victim  of  this  disease 
who  was  discovered  in  a  village  in  Maryland  about  two  years  ago 
is  shameful,  productive  of  no  good  to  the  general  public,  and  an 
insult  to  twentieth  century  knowledge. 

Of  the  diseases  of  unknown  etiology,  yellow  fever  has  been 
our  most  serious  tropical  problem.  The  disease  is  endemic  in  Cuba 
and  in  Brazil  and  has  frequently  been  seen  in  epidemic  outbreaks 
in  our  Southern  states  and  in  Central  and  South  America.  Some 
cases  have  been  seen  on  the  west  coast  of  Africa,  and  epidemics 
have  occurred  in  the  past  in  Philadelphia,  New  York,  and  Baltimore. 

The  work  of  the  Yellow  Fever  Commission  of  the  United 
States  Army  in  Havana,  in  1900,  has  proved  that  the  disease  is 
transmitted  by  the  bite  of  infected  Stegomyia  calopus  mosquitoes. 
The  problem  of  prevention  of  epidemics,  therefore,  resolves  itself 
into  the  destruction  of  Stegomyia  calopus.  This  was  successfully 
demonstated  in  New  Orleans  in  1908.  Stegomyia  calopus  appar- 
ently always  breeds  in  artificial  collections  of  fairly  clean  water. 
Consequently  the  screening  of  cisterns,  wells  and  reservoirs  is  abso- 
lutely necessary.  The  patient  must  be  treated  in  a  ward  or  an 
apartment  screened  from  the  access  of  mosquitoes,  and  the  apart- 
ment from  which  he  was  removed  at  the  onset  of  the  disease  must 
be  fumigated  for  the  purpose  of  killing  what  adult  mosquitoes 
may  be  contained  in  it;  but  for  no  other  reason.  The  patient  is 
harmless,  except  he  is  bitten  during  the  first  three  or  four  days 
of  his  illness. 

The  American  people  owe  a  debt  of  gratitude  to  Dr.  James 
Carroll,  Dr.  Walter  Reed,  Dr.  Jesse  Lazear,  and  Dr.  Aristides 
Agramonte  which  pensions  and  monuments  can  but  partially  repay. 
It  is  a  parsimonious  congress  indeed  that  will  neglect  the  widows 
of  Dr.  Carroll  and  Dr.  Reed  while  it  corrects  the  military  records 
of  patriotic  deserters. 

Dengue  is  frequently  met  with  in  epidemic  form  in  the  Southern 
United  States  and  in  the  West  Indies.  It  is  a  considerable  factor 
in  morbidity  statistics  in  the  Philippine  Islands.  It  is  met  with  in 
many  tropical  and  subtropical  countries.  It  is  not  dangerous  to  life, 
the  death  rate  being  less  than  one  per  cent,  and  the  fatal  cases 
being  seen  in  individuals  who  were  already  suffering  from  some 
chronic  complaint  when  attacked  by  dengue.     Our  knowledge  of 

(409) 


i66  The  Annals  of  the  American  Academy 

the  transmission  of  dengue  is  due  to  the  work  of  the  United  States 
Army  Board  for  the  study  of  tropical  diseases  as  they  occur  in 
the  Philippine  Islands,  Dr.  P.  M.  Ashburn  and  Dr.  Charles  F.- 
Craig. These  investigators,  following  the  methods  pursued  by 
the  Yellow  Fever  Commission  in  Cuba,  have  demonstrated  the 
transmission  of  the  disease  by  the  mosquito  Culex  fatigans.  The 
prevention  of  epidemics  of  dengue  is  a  question  of  mosquito  exter- 
mination. 

Beriberi  is  a  disease  indigenous  to  China,  Japan,  the  Philippine 
Islands,  the  Malay  Peninsula,  and  India.  It  is  characterized  by 
an  acute  febrile  period,  followed  by  dropsy,  and  later,  by  paralysis. 
The  cause  of  the  disease  is  unknown.  The  majority  of  students 
of  tropical  pathology  are  of  the  opinion  that  it  is  the  result  of  the 
consumption  of  spoiled  rice.  Some  few  observers  believe  it  to 
be  dependent  upon  an  unknown  parasite. 

The  presence  of  a  case  of  beriberi  upon  a  vessel  from  an 
Indian,  a  Chinese,  or  a  Japanese  port  is  no  excuse  for  scareheads 
in  the  newspapers.  It  is  perfectly  safe  to  treat  such  a  patient  in 
the  general  wards  of  a  New  York  hospital. 

Conclusion. — It  is  no  part  of  the  intention  of  the  writer  of 
this  paper  to  increase  the  causes  of  uneasiness  of  certain  suscep- 
tible individuals  among  his  countrymen.  The  knowledge  that  cer- 
tain diseases  exist,  that  they  have  well  known  causes,  that  they 
are  disseminated  by  well  understood  agents,  and  that  their  spread 
can  be  prevented  by  well  tried  methods,  should  make  for  peace 
of  mind  rather  than  for  worry.  A  man  who  is  on  his  way  home 
at  night  will  not  fall  into  the  ditch,  provided  he  knows  where  the 
ditch  is.  The  knowledge  of  the  existence  of  an  epidemic  disease 
is  the  most  important  element  of  the  campaign  to  eradicate  the 
disorder. 

The  application  of  the  various  sanitary  methods  referred  to 
in  the  course  of  this  paper  is  of  the  first  importance  wherever  men 
are  gathered  together.  We  are  fairly  well  informed  as  to  the  value 
of  a  noncontaminated  water  supply,  of  a  clean  milk  supply,  of 
clean  streets,  of  proper  garbage  and  sewage  disposition.  All  these 
things  cost  money,  but  we  now  know  that  the  money  is  well  spent. 
Campaigns  of  mosquito  extermination,  of  fly  destruction,  of  rat 
and  mouse  extirpation  will  be  found  to  be  investments  that  will  pay. 

(410) 


Tropical  Diseases  and  Health  in  United  States  167 

In  the  Nobel  Lecture  at  Harvard  on  December  14,  1910,  ex- 
President  Roosevelt  said: 

Many  men  have  rendered  high  and  honorable  service  to  the  United 
States  in  connection  with  the  work  of  the  Panama  Canal,  but  by  far  the 
greatest  and  most  important  work  has  been  rendered  by  Colonel  Goethals. 
It  is  to  him  more  than  to  any  other  one  man  that  we  owe  the  successful 
accomplishment  of  one  of  the  great  business  and  engineering  feats  of  all 
the  ages. 

When  it  is  completed,  Colonel  William  C.  Gorgas  will  have 
made  possible  "more  than  any  other  one  man"  the  construction 
of  the  Panama  Canal.  The  Canal  would  have  been  a  French 
achievement,  had  it  not  been  for  yellow  fever  and  malaria.  What- 
ever of  dishonesty  in  affairs  may  have  existed  in  the  French  com- 
pany was  of  small  import  beside  these  two  tropical  diseases. 
Shoulder  straps  have  never  prevented  the  bite  of  a  malaria  carrier, 
nor  of  a  yellow  fever  carrier. 

[Note. — The  author  would  acknowledge  his  indebtedness  to  Mr.  George 
S.  Bliss,  of  the  Philadelphia  office  of  the  United  States  Weather  Bureau, 
for  valuable  help  concerning  the  climatological  data  herein  contained.] 


(411) 


THE  HOUSE  FLY  AS  A  CARRIER  OF  DISEASE 


By  Edward  Hatch,  Jr., 
Chairman,  Fly-Fighting  Committee,  American  Civic  Association,  New  York. 


The  common  house  fly  has  been  a  follower  of  mankind  since 
the  beginning  of  history,  as  doubtless  he  was  for  ages  before.  He 
is  found  only  where  man  has  made  his  home;  and  the  newest 
pioneer  settlements  soon  have  a  fly  population  proportionately 
larger  than  the  older  communities.  The  Egyptian  plague  of  flies 
is  recorded  in  the  Book  of  Exodus  in  terms  which  indicate  that 
the  author  of  the  Pentateuch  looked  upon  these  insects  as  some- 
thing more  than  mere  nuisances;  for  he  says:  "The  land  was  cor- 
rupted by  reason  of  the  swarm  of  flies"  (Ex,  viii.  24)  ;  and  their 
potentialities  for  evil  were  more  than  hinted  at  in  the  name  of 
the  Canaanite  god  Baal-Zebub  (Prince  of  Flies),  which  in  the  reli- 
gious language  of  a  later  day  became  an  alternative  term  for  the 
devil  himself. 

While  the  sacred  writers  seem  to  have  had  some  appreciation 
of  the  pestiferous  nature  of  the  fly,  references  to  him  in  modern 
literature  have  been  usually  of  a  sportive  and  flippant  character; 
he  has  been  either  the  subject  of  jests  or  a  symbol  of  weakness 
and  harmlessness.  Children  have  been  taught  that  they  must  save 
the  interesting  little  creature  when  he  seems  likely  to  drown  in  a 
mug  of  milk.  It  is  only  comparatively  recently  that  he  has  been 
revealed  in  his  true  colors  and  shown  to  have  earned  the  title  of 
"the  most  dangerous  animal  on  earth. "^ 

When  the  Water  Pollution  Committee  of  the  New  York  Mer- 
chants' Association  was  founded  a  few  years  ago,  one  of  the  first 
questions  for  its  consideration  was  the  menace  to  health  consti- 
tuted by  the  pollution  of  New  York  Harbor — a  menace  whose 
existence  had  been  denied  by  certain  scientific  authorities.  The 
committee  therefore  made  an  investigation  of  the  conditions  pre- 
vailing along  the  waterfront  of  Manhattan  Island,  and  proceeded 
to  show  the  relation  between  them  and  the  death  rate  of  the  dis- 
tricts in  the  immediate  neighborhood  of  the  docks.  Dr.  Daniel  D. 
Jackson,  who  conducted  the  investigation  as  a  member  of  the  com- 

*  Daniel  D.  Jackson  in  "The  House-Fly  at  the  Bar." 

(412) 


The  House  Fly  as  a  Carrier  of  Disease  169 

mittee,  finding  that  flies,  attracted  by  the  dry  and  floating  sewage 
in  sHps  and  on  the  wharves,  swarmed  along  the  waterfront,  set 
a  large  number  of  traps  at  different  points  on  the  North  and  East 
river  shores.  Counting  the  flies  every  day,  he  grouped  his  results 
by  weeks,  thus  allowing  for  both  sunny  .  and  rainy  days.  His 
captives  carried  innumerable  fecal  bacilli  on  their  legs  and  bodies — 
one  fly,  taken  in  South  street,  having  more  than  125,000  about  him. 
He  found  that  the  increase  in  the  number  of  such  intestinal  diseases 
as  typhoid  fever  and  the  summer  diarrhcea  of  infants  was  in  direct 
proportion  to  the  increase  in  the  number  and  activity  of  flies.  He 
presented  with  the  report  a  map  of  the  Borough  of  Manhattan, 
with  cases  of  typhoid  and  intestinal  diseases  indicated  by  black 
dots,  by  which  it  was  shown  that  the  vast  majority  of  these  cases 
were  to  be  found  in  the  parts  of  the  city  nearest  the  polluted 
waterfront.  A  thoroughgoing  reform  of  general  sanitary  conditions 
in  the  districts  affected,  including  the  adoption  of  some  system 
of  sewage  disposal,  would,  the  report  stated,  reduce  the  yearly 
typhoid  deaths  in  New  York  very  considerably,  and  the  diarrhoeal 
deaths  from  7,000  to  2,000 — if  germ-infected  flies  were  not  per- 
mitted to  contaminate  the  milk  supply  before  it  reached  the  city 
or  after.  In  addition  to  the  lives  thus  saved,  the  reforms  recom- 
mended would  reduce  the  number  of  cases  of  illness  from  these 
causes  about  50,000  annually. 

The  Jackson  report,  published  by  the  committee  under  the 
title  "Pollution  of  New  York  Harbor  as  a  Menace  to  Health  by 
the  Dissemination  of  Intestinal  Diseases  through  the  Agency  of 
the  Common  House-Fly"  (December,  1907),  was  widely  circulated, 
and  is  perhaps  the  best  known  record  of  experiments  tending  to 
establish  the  responsibility  of  flies  for  the  spread  of  disease-produc- 
ing bacteria.  Confirmatory  testimony  is  furnished  by  many  other 
authorities,  as  the  result  of  investigations  carried  on  in  various 
parts  of  the  world,  so  that  we  need  no  longer  speak  of  an  hypothesis 
of  disease  transmission  by  flies,  but  may  regard  the  fact  of  such 
transmission  as  scientifically  established.  I  shall  in  this  paper 
adduce  only  a  small  part  of  the  great  body  of  testimony,  before 
proceeding  to  the  discussion  of  the  means  which  to  me  as  a  layman 
— but  a  layman  who  has  given  much  time  and  attention  to  the 
problem — seem  most  likely  to  accomplish  the  extermination  of  the 
pest.     I  may  say  in  passing  that,  though  to  the  readers  of  The 

(413) 


170  The  Annals  of  the  American  Academy 

Annals  it  is  not  necessary  to  apologize  for  the  plain  treatment 
of  the  disagreeable  phases  of  the  subject,  such  treatment  is  some- 
times offensive  to  over-sensitive  members  of  a  popular  audience, 
as  the  committee  has  more  than  once  found  to  its  sorrow — as  when 
in  a  city  in  Indiana  the  authorities  forbade  the  showing  of  its 
moving  pictures  illustrating  the  dangers  of  the  fly  nuisance,  on  the 
ground  that  they  were  too  disgusting  to  be  presented  in  public. 

A  little  more  than  a  year  ago,  Dr.  L.  O.  Howard,  Entomologist 
of  the  United  States  Department  of  Agriculture,  proposed  the  name 
of  "typhoid  fly"  as  a  substitute  for  that  of  "house  fly,"  commonly 
used  to  designate  Musca  domcstica.  His  suggestion,  while  it  has 
not  actually  changed  current  nomenclature,  has  been  so  widely 
commented  upon  that  it  has  accomplished  much  in  the  way  of 
impressing  the  popular  mind  with  the  fly's  dangerous  activities. 
With  true  scientific  conscientiousness.  Dr.  Howard  explained  that, 
"strictly  speaking,  the  term  is  open  to  some  objection,  as  convey- 
ing the  erroneous  idea  that  the  fly  is  solely  responsible  for  the 
spread  of  typhoid;  but  considering  that  the  creature  is  dangerous 
from  every  point  of  view,  and  that  it  is  an  important  element  in 
the  spread  of  typhoid,  it  seems  advisable  to  give  it  a  name  which 
is  almost  wholly  justified  and  which  conveys  in  itself  the  idea  of 
serious  disease." 

There  is  little  danger  that  any  other  fly  may  be  made  by  indig- 
nant housewives  or  health  officers  to  suffer  for  the  sins  of  Musca 
domestica,  for  this  variety  constitutes  ninety-eight  per  cent  of  the 
fly  population  of  American  houses.  A  condensed  account  of  its 
habits^  will  suffice  to  indicate  the  ways  in  which  it  may  carry 
germs  from  filth  to  human  food. 

Born  in  manure,  generally  that  of  the  horse,  or  in  decomposing  matter 
of  any  kind,  vegetable  as  well  as  animal,  they  enter  our  homes  to  alight 
on  foods  there  stored.  Their  tastes  are  indelicate  and  omnivorous;  but  they 
subsist  on  sputum,  fecal  juices,  and  the  slime  and  dirt  that  sticks  to 
exposed  surfaces.  Their  proboscides,  through  which  they  feed,  are  con- 
nected with  an  extremely  active  salivary  gland,  capable  of  pouring  out  a  large 
quantity  of  saliva,  which  the  fly  projects  against  a  dry  surface,  swallowing 
the  subsequent  solution.  Naturally,  solid  particles,  living  organisms,  para- 
sites, and  eggs,  small  enough,  may  pass  into  the  digestive  tube.  Bacilli 
of  different  types   and   eggs   of   the   nematodes  have  been   observed   in  the 

''As  given  by  Dr.  Gordon  K.  Dickinson,  in  tho  Now  York  "Medical  Record," 
January  26,  1907. 

(414) 


The  House  Fly  as  a  Carrier  of  Disease  171 

proboscides,  stomach,  intestinal  tract  and  dejections.  The  time  that  particles 
remain  in  the  digestive  tract  of  the  fly  is  from  twelve  to  twenty-three  days. 
Evidently  the  digestive  secretions  are  not  active  for  harm,  as  organisms 
will  not  only  pass  through  alive,  but  increase  in  number  while  in  transit. 
There  must  be  some  absorption  of  the  toxins  of  bacilli,  for  flies  die  in  large 
numbers  which  have  had  the  fortune  to  imbibe  such  bacilli  as  those  of  the 
plague  and  anthrax.  Flies  are  large  breeders,  lay  their  eggs  by  prefer- 
ence in  horse  manure,  but  also  in  decaying  meat,  meat  broth,  cut  melons, 
dead  animals,  and  even  in  cuspidors.  On  these  substances  their  larvae  sub- 
sist until  they  hatch.  From  ten  days  to  two  weeks  after  the  time  the  eggs 
have  been  laid  the  fly  is  fully  hatched.  It  is  estimated  that  one  fly,  laying 
120  eggs  at  a  time,  will  have  a  progeny  amounting  up  to  the  sextillions  at 
the  end  of  the  season. 

The  earliest  convincing  evidence  of  the  part  played  by  house 
flies  in  the  dissemination  of  the  typhoid  bacillus  was  furnished 
by  Drs.  Vaughan,  Veeder,  Reed,  Sternburg  and  Shakespeare,  who 
investigated  camp  conditions  during  the  Spanish-American  War. 
Dr.  Vaughan,  a  member  of  the  U.  S.  .Army  Typhoid  Commission 
of  1898,  summarized  his  reasons  for  believing  that  flies  were  active 
in  the  dissemination  of  typhoid  fever  in  these  paragraphs:' 

(0)  Flies  swarmed  over  infected  fecal  matter  in  the  pits  and  then  vis- 
ited and  fed  upon  the  food  prepared  for  the  soldiers  in  the  mess-tents.  In 
some  instances  where  lime  had  recently  been  sprinkled  over  the  contents  of 
the  pits,  flies  with  their  feet  whitened  with  lime  were  seen  walking  over 
the  food. 

(b)  Ofiicers  whose  mess-tents  were  protected  by  screens  suffered  pro- 
proportionately  less  from  typhoid  fever  than  did  those  whose  tents  were  not 
protected. 

(c)  Typhoid  fever  gradually  disappeared  in  the  fall  of  1898  with  the 
approach  of  cold  weather  and  the  consequent  disabling  of  the  fly. 

It  is  possible  for  the  fly  to  carry  typhoid  bacillus  in  two  ways.  In  the 
first  place  fecal  matter  containing  the  typhoid  germs  may  adhere  to  the  fly 
and  be  mechanically  transported.  In  the  second  place,  it  is  possible  that  the 
typhoid  bacillus  may  be  carried  in  the  digestive  organs  of  the  fly  and  may  be 
deposited  with  its  excrement. 

The  observations  and  deductions  of  American  surgeons  were 
corroborated  by  the  British  medical  officers  in  the  Boer  War. 
"Nothing,"  says  Dr.  Dunne,  writing  in  1902,  "was  more  noticeable 
than  the  fall  in  the  admissions  from  enteric  (typhoid)  fever  coin- 
cident with  the  killing  off  of  the  flies  on  the  advent  of  the  cold 

» 'ToncUisions  Rpachod  After  a  Study  of  Typhoid  Fever  Among  American  Sol- 
diers."    A  paper  read  before  tiie  American  Medical  Association,  1900. 

(415) 


172  The  Annals  of  the  American  Academy 

nights  of  May  and  June.  In  July,  when  1  had  occasion  to  visit 
Bloemfontein,  the  hospitals  there  were  half  empty  and  had  prac- 
tically become  convalescent  camps." 

That  the  conditions  which  prevailed  in  military  camps  before 
the  deadly  work  of  the  fly  was  recognized  are  to  be  found  in  many 
communities  in  time  of  peace,  and  that  their  agency  in  spreading 
disease  is  equally  effective,  may  be  seen — to  select  only  one  from 
numerous  instances — from  the  report  of  Dr.  Alice  Hamilton  on  the 
typhoid  fever  epidemic  in  Chicago  in  July-September,  1902.  Two 
places  in  the  neighborhood  of  Hull  House  were  selected  as  espe- 
cially favorable  for  an  investigation  of  the  relations  between  flies 
and  the  epidemic. 

The  first  was  an  unconnected  privy  on  Polk  street,  into  which  the  dis- 
charges from  two  cases  of  typhoid  fever  were  being  thrown  vvitliout  any 
attempt  at  disinfection.  The  vault  was  either  very  shallow  or  very  full,  for 
the  dejecta  lay  within  three  feet  of  the  opening  and  had  caught  on  the  pro- 
jecting scantling  within  a  foot  of  the  opening.  The  flies  caught  within  the 
vault,  on  the  fence  of  the  yard,  and  inside  the  sickroom  of  one  of  the 
patients,  which  was  also  used  as  a  kitchen,  were  dropped  into  test  tubes 
containing  culture  medium  and  allowed  to  remain  there  for  periods  varying 
from  fifteen  minutes  to  twelve  hours,  and  .were  taken  to  the  laboratory 
of  the  Memorial  Institute  for  Infectious  Diseases  for  examination.  The 
full  details  of  this  part  of  the  investigation  have  been  published  in  the 
"Journal  of  the  American  Medical  Association."  In  two  of  the  tubes,  the 
one  from  the  sickroom  and  the  one  from  the  yard,  the  typhoid  bacillus  was 
discovered.  In  one  of  the  tubes  inoculated  by  flies  from  the  vault  a  bacillus 
was  discovered  closely  related  to  but  not  identical  with  the  typhoid  bacillus, 
belonging  apparently  to  the  group  intermediate  between  the  typhoid  and 
colon  groups.  This  is  a  group  of  bacilli  which  have  been  isolated  from 
patients    suffering    from    typhoid-like    affections. 

The  second  place  chosen  was  a  yard  on  Aberdeen  street,  containing  one 
large,  full  and  filthy  vault,  not  connected  with  the  sewer.  This  is  used  by 
sixteen  families.  Flies  from  three  privies  built  over  this  cesspoool  were  used 
to  inoculate  four  tubes.  Other  flies  from  the  fence  of  the  yard  and  from 
the  walls  of  the  two  houses  bounding  the  yard  at  varying  distances  from 
the  vault  were  dropped  into  six  tubes.  In  three  of  these  tubes  the  typhoid 
bacillus  was  discovered. 

Further  bacteriological  evidence  of  the  transmission  by  flies 

of  the  typhoid  bacillus   is   adduced   by   Dr.    C.    Gordon   Hewitt,* 

*  In  "The  Structure,  Development  and  Bionomics  of  the  House-Fly,  Musca  domes- 
tica,  Linn.  Part  III.  The  Bionomics,  Allies,  Parasites,  and  the  Relations  of  M. 
domestica  to  Human  Disease." 

(416) 


The  House  Fly  as  a  Carrier  of  Disease  173 

Dominion  Entomologist,  of  Ottawa.  He  records  the  recovery  by 
Celli  (1888),  of  the  Bacillus  typhi  abdominalis,  from  the  dejec- 
tions of  flies  which  had  been  fed  upon  cultures  of  the  same,  and 
his  proof  that  the  bacilli  passed  through  the  alimentary  tract  in  a 
virulent  state.  Ficken,  in  1903,  found  that  **when  flies  were  fed 
upon  typhoid  cultures  they  could  contaminate  objects  upon  which 
they  rested.  The  typhoid  bacilli  were  present  in  the  head  and  on 
the  wings  and  legs  of  the  fly  five  days  after  feeding,  and  in  the 
alimentary  tract  nine  days  after." 

Flies  also  certainly  transmit,  according  to  Dr.  Flewitt,  and 
other  scientific  investigators,  the  bacilli  of  tuberculosis,  cholera, 
anthrax,  bubonic  plague,  and  possibly  those  of  ophthalmia  and  one 
or  two  more  loathsome  diseases.  But  if  we  confine  our  considera- 
tion to  its  connection  with  typhoid  fever  alone,  we  must  hold  the 
fly  responsible  for  a  large  proportion  of  the  vast  money  loss  which 
this  country  annually  suffers  from  the  ravages  of  that  disease. 
Dr.  G.  N.  Kober,  of  Washington,  has  estimated  that  the  decrease 
in  the  vital  assets  of  the  United  States  through  typhoid  fever  in 
a  single  year  is  more  than  $350,000,000.  Physicians  are  not  unani- 
mous as  to  the  proportion  of  responsibility  for  typhoid  which  must 
be  assigned  to  flies,  polluted  water  and  infected  milk,  but  most  of 
them  agree  in  crediting  flies  with  a  very  important  part  in  its 
dissemination ;  and  when  to  this  vast  sum  is  added  the  $10,000,000 
which  the  people  of  this  country  pay  annually  for  screens  to  pro- 
tect themselves  against  flies  and  mosquitoes,  we  have  what  should 
be  a  tremendously  eflFective  argument  in  favor  of  the  extermina- 
tion of  the  fly  pest — even  without  the  infinitely  more  potent  appeal, 
if  it  could  be  made  personal,  to  each  of  us  to  guard  the  health 
and  lives  of  ourselves  and  our  families. 

For  the  fly  plague  is  not  one  which  must  be  endured  as  a 
visitation  of  Providence.  It  may  be  stamped  out  by  the  systematic 
adoption  of  one  method,  and  only  one,  by  the  individual  and  the 
public — the  method  of  cleanliness.  The  fly  is  bred  in,  lives  and 
thrives  upon,  filth.  If  you  allow  no  filth  to  accumulate  in  your 
house  and  your  neighborhood,  you  will  not  be  troubled  by  flies,  for 
they  do  not,  ordinarily,  stray  far  from  their  breeding  places  and 
their  sources  of  food  supply.  Even  if  they  should  enter  a 
thoroughly  clean  neighborhood,  they  could  not  exist  in  the  face  of 
screens   preventing  their   access   to   food   and   in  the  absence   of 

(417) 


174  The  Annals  of  the  American  Academy 

manure  heaps  and  other  receptacles  of  filth  in  which  to  deposit 
their  eggs.  Those  who  conduct  local  campaigns  against  the  house 
fly  cannot  too  strongly  emphasize  the  dictum  of  the  Fly-Fighting 
Committee  of  the  American  Civic  Asociation,  "If  there  is  no  filth 
there  will  be  no  flies." 

One  result  of  the  investigations  made  by  Dr.  Jackson  into  the 
relations  existing  between  flies  and  sewage  was  the  prosecution, 
at  first  within  the  Water  Pollution  Committee  of  the  New  York 
Merchants'  Association,  and  later  through  a  special  committee  of 
the  American  Civic  Association,  of  a  campaign  of  education  and 
extermination  directed  against  the  fly.  A  summary  of  the  activities 
of  this  committee  will  furnish  suggestions  for  those  who  desire  to 
co-operate  in  the  general  reform  through  local  organized  effort. 

The  committee,  as  now  constituted,  is  somewhat  larger  than 
in  the  period  of  its  connection  with  the  Merchants'  Association, 
and  most  of  the  members  of  the  Water  Pollution  Committee,  in 
which  it  had  its  beginnings,  are  members  of  the  new  committee 
(formed  in  February,  1910).  This  close  association  of  the  two 
committees  is  appropriate,  for  nearly  everywhere — in  the  small 
towns  perhaps  more  even  than  in  the  great  cities — untreated  and 
unprotected  sewage  makes  the  banks  of  watercourses  the  gathering 
and  breeding-places  of  flies.  The  membership  of  the  Fly-Fighting 
Committee  is  as  follows:  Edward  Hatch,  Jr.,  of  New  York,  chair- 
man ;  Dr.  Daniel  D.  Jackson,  Dr.  Woods  Hutchinson  and  Col.  John 
Y.  Culyer,  of  New  York ;  Harlan  P.  Kelsey,  of  Salem,  Mass. ; 
Mrs.  Caroline  Bartlett  Crane,  of  Kalamazoo,  Mich. ;  Dr.  S.  J. 
Crumbine,  State  Commissioner  of  Health,  of  Topeka,  Kan. ;  Dr. 
Joseph  Y.  Porter,  State  Commissioner  of  Health,  of  Jacksonville, 
Fla. ;  Dr.  Albert  VanderVeer,  of  Albany,  N.  Y. ;  Mrs.  R.  S.  Bradley, 
of  Boston,  Mass. ;  Miss  Alice  Lakey,  of  the  Food  Committee  of 
the  National  Consumers'  League,  of  Cranford,  N.  J.,  and  Mrs. 
Gardner  Raymond,  of  Rochester,  N.  Y. 

Each  member  of  the  committee  is  a  center  for  his  or  her  part 
of  the  country — and  the  members  are  pretty  widely  distributed, 
geographically — for  the  dissemination  of  educational  literature  bear- 
ing upon  the  subject  of  flies,  and  so  well  has  the  work  been  done 
that  very  few  people  who  read  the  newspapers  can  plead  ignorance 
of  fly  dangers  as  an  excuse  for  not  excluding  the  pest  from  their 
neighborhoods  and  their  houses.    The  committee  sends  free  to  phy- 

(418) 


The  House  Fly  as  a  Carrier  of  Disease  175 

sicians,  health  officers,  teachers,  social  workers — in  fact  to  any 
one  who  expresses  an  interest  in  the  subject — such  literature,  pre- 
pared under  its  direction,  as  "The  House-Fly  at  the  Bar"  (a 
compilation  of  scientific  opinions,  popularly  expressed,  as  to  the 
fly's  guilt  in  the  matter  of  disease  dissemination)  ;  "Rules  for  Deal- 
ing with  the  Fly  Nuisance"  (for  posting  in  hotels,  schools,  fac- 
tories, stores,  etc.),  and  "Beware  of  the  Dangerous  House-Fly"  (a 
simply-worded  tract  for  popular  distribution,  particularly  among 
school  children).  One  of  the  most  effective  and  popular  means 
of  bringing  home  to  the  average  person  what  it  means  to  allow 
the  fly  to  flourish  and  have  free  access  to  houses  and  food  is  the 
moving  picture  film,  entitled  "The  Fly  Pest,"'  made  in  Europe  under 
the  auspices  of  a  representative  of  the  committee,  which  has  been 
shown  in  hundreds  of  moving  picture  halls  and  is  still  a  "drawing 
card."  The  series  of  pictures  shows  flies  (as  big  as  Plymouth 
Rock  hens,  as  they  appear  on  the  screen)  laying  eggs  in  filth;  the 
eggs  in  white  masses ;  the  maggots  in  writhing  heaps  as  they  emerge 
from  the  eggs,  and  in  different  stages  of  their  growth  as  maggots, 
until  they  burrow  in  the  dirt  to  enter  the  pupa  state ;  the  pupae 
(or  grubs)  themselves,  one  day  later;  flies  emerging  from  the  filth, 
at  first  wingless;  then  the  perfect  adult  fly.  Then  follow  pictures 
stretching  across  the  screen,  of  a  fly  taking  a  sip  of  honey  from 
the  point  of  a  needle,  showing  the  action  of  the  proboscis,  very 
like  an  elephant's  trunk  in  miniature ;  of  the  tongue,  and  of  the 
foot,  also  enormously  enlarged,  and  with  every  microscopic  hair 
distinct. 

The  second  act  of  this  little  life  history  is  entitled  "How  Flies 
Carry  Contagion."  In  it  these  scenes  follow  one  anotiier  in  rapid 
succession,  so  that  the  most  thoughtless  spectator  cannot  fail  to 
grasp  their  full  significance:  flies  swarming  over  putrid  fish;  crawl- 
ing over  lumps  of  sugar;  in  a  cuspidor;  on  the  nipple  of  a  baby's 
feeding  bottle,  and,  last  of  all.  a  pretty  baby  placidly  sucking  the 
mouthpiece  from  which  the  flies  have  just  departed. 

The  usefulness  of  this  method  of  propaganda  is  shown  by 
the  action  of  Dr.  W.  A.  Evans,  health  officer  of  Chicago,  who  has 
been  giving  free  lectures  on  the  fly  pest  in  the  moving-picture 
theatres  in  that  city.  All  over  the  country  there  has  been  gratifying 
co-operation  in  this  educational  work  between  enlightened  moving- 

» Controlled  by  the  Kleine  Optical  Company,  Chicago,  111. 

(419) 


176  The  Annals  of  the  American  Academy 

picture  showmen  and  the  various  agencies  working  for  fly  exter- 
mination. 

Lantern  slides  iUustrating  the  same  subject  as  the  fihn,  to  be 
used  in  lectures  for  which  moving  pictures  are  not  available,  are 
loaned  to  responsible  persons  who  make  application  to  the  com- 
mittee. A  traveling  exhibit,  consisting  of  photographs  illustrating 
and  placards  warning  against  the  fly  pest,  is  also  to  be  had  by  local 
organizations  which  guarantee  to  pay  express  charges  and  to  return 
it  intact.  The  pictures  and  placards  are  mounted  on  a  folding 
screen,  about  six  feet  high,  and  the  whole  exhibit  may  be  packed 
snugly  in  a  substantial  wooden  box  which  accompanies  it. 

The  committee  plans  this  year  (1911)  to  extend  its  educational 
campaign  among  the  school  children,  and  to  this  end  has  insti- 
tuted a  system  of  prize  competitions  in  essay  writing  on  the  subject, 
"The  House  Fly  as  a  Carrier  of  Disease."  The  pupils  of  the  public 
and  parochial  schools  taking  part  in  these  competitions  will  be 
supplied  with  the  material  for  their  essays,  contained  largely  in  the 
"literature"  to  which  reference  has  already  been  made. 

Another  line  of  work  has  been  projected,  namely,  the  prepara- 
tion of  a  "white  list"  of  hotels  and  summer  resorts  that  take 
proper  precautions  against  the  fly  pest;  information  being  solicited 
from  all  members  of  the  American  Civic  Association. 

Now  for  a  few  practical  suggestions  as  to  the  means  of  exter- 
minating the  pest.    Dr.  Howard  says: 

Even  if  the  typhoid  or  house  fly  were  a  creature  difficult  to  destroy, 
the  general  failure  on  the  part  of  communities  to  make  any  efforts  whatever 
to  reduce  its  numbers  could  properly  be  termed  criminal  neglect;  but  since 
it  is  comparatively  an  easy  matter  to  do  away  with  the  plague  of  flies,  this 
neglect  becomes  an  evidence  of  ignorance  or  of  a  carelessness  in  regard  to 
disease-producing  filth  which  to  the  informed  mind  constitutes  a  serious  blot 
on  civilized  methods  of  life. 

The  methods  of  ridding  a  neighborhood  of  flies  are,  as  Dr. 
Howard  has  intimated,  comparatively  simple,  or  would  be  so,  at 
any  rate,  to  a  fly-fighter  with  despotic  power  over  a  community. 
For  to  insure  the  success  of  this  work  co-operation  is  absolutely 
essential.  One  carelessly  conducted  stable  may  nullify  the  con- 
scientious efiforts  of  a  whole  neighborhood  of  fly-fighters,  although 
they  always  have  the  resource  of  bringing  moral  suasion  to  bear 
upon  the  proprietor  of  that  stable.     But  while  the  creation  of  a 

(420) 


The  House  Fly  as  a  Carrier  of  Disease  177 

proper  community  spirit  is  necessary — a  spirit  which  snail  bring 
home  to  each  householder  his  responsibility  for  maintaining  sani- 
tary conditions  on  his  premises — the  benevolent  despotism  of  the 
health  officer  is  the  most  effective  single  agency  for  carrying  out 
the  reforms  for  which  this  committee  is  striving.  Fortunately,  the 
great  majority  of  health  officers  are  so  thoroughly  alive  to  the 
dangers  of  the  fly  pest  that  they  are  at  least  willing  to  enforce 
any  fly  ordinances  which  public  opinion  is  strong  enough  to  have 
enacted,  even  if  they  are  not,  as  they  generally  are,  pioneers  in  the 
anti-fly  movement. 

Such  pioneers  are  the  members  of  the  Indiana  State  Board  of 
Health,  who  have  framed  and  sent  to  the  mayors  of  all  the  cities 
in  the  state  the  following  ordinance : 

Whereas,  It  is  commonly  known  that  flies  are  very  dangerous  carriers 
of  filth,  filth  poisons,  and  disease  germs,  that  they  are  lx>rn  in  filth,  and  arc 
a  constant  threat  against  the  health,  happiness  and  prosperity  of  the  people; 
tlicrefore, 

Section   i.     Be   it  or<lained  by  the   Mayor  and   Council  of  the  city  of 

,  that  it  shall  be  unlawful  for  any  person,  firm  or  corporation  to 

suffer  or  permit  or  have  upon  their  premises,  whether  owned  or  leased  by 
them,  any  one  or  more  of  the  following  unsanitary  fly-producing,  disease- 
causing  conditions,  to  wit:  (i)  Animal  manure  in  any  quantity  which  is  not 
securely  protected  from  flies;  (2)  privies,  vaults,  cesspools,  pits  or  like 
places,  which  are  not  securely  protected  from  flies;  (3)  garbage  in  any 
quantity  which  is  not  securely  protected  from  flies;  (4)  trash,  litter,  rags 
or  anything  whatsoever  in  which  flies  may  breed  or  multiply. 

Section  2.  It  shall  be  the  duty  of  the  chief  of  police  or  city  marshal 
and  health  officers,  upon  learning  in  any  way  whatsoever  of  the  exi.stence 
of  one  or  more  of  the  unlawful  conditions  described  in  Section  i  of  this 
ordinance,  to  notify  the  offender  in  writing,  upon  order  blanks  provided 
by  the  city  clerk,  to  remove  or  abate  said  unlawful  conditions,  stating  th^ 
shortest  reasonable  time  for  such  removal  or  abatement.  In  the  event  of 
the  refusal  or  neglect  on  the  part  of  the  notified  offender  to  obey  such  order, 
the  chief  of  police  or  health  officer  shall  inform  the  street  connnissioner. 
upon  a  blank  provided  by  the  city  clerk,  and  it  shall  then  be  the  duty  of 
said  street  commissioner,  and  he  shall  have  power  and  authority,  to  remove 
and  abate  the  reported  uidawful  conditions;  and  he  shall  keep  an  accurate 
account  of  the  cost  and  expenses  therof.  which  shall  be  paid  from  the  city 
treasury  upon  the  sworn  vouchers  of  the  street  commissioner,  and  said  cost 
and  expenses  shall  be  a  lien  upon  the  property  and  shall  be  collected  by  law 
as  taxes  are  collected  and  duly  paid  into  the  city  treasury. 

Section  3.  Any  person,  firm,  or  corporation  found  g'ilty  of  having 
created   or   suffered   to  exist  on   premises  either  owned  or  leased  by  them 

(421) 


1/8  The  Annals  of  the  American  Academy 

any  one  or  more  of  the  unlawful  conditions  named  in  Section  i  of  this 
ordinance  shall  be  punished  by  a  fine  of  not  less  than  five  or  more  than  fifty 
dollars. 

Section  4.  All  ordinances  or  parts  of  ordinances  in  conflict  with  this 
ordinance  are  hereby  repealed;  and  whereas  an  emergency  exists,  this  ordi- 
nance shall  be  in  effect  upon  and  immediately  after  its  passage. 

This  draft  of  a  proposed  ordinance,  which  I  consider  admirable 
as  directing  attention  to  filth  as  the  sole  cause  for  the  existence 
of  flies,  has  been  copied  by  the  Kansas  and  California  boards  of 
health  and  extensively  circulated  in  those  states.  I  hope  the  time 
may  soon  come  when  we  shall  see  every  city  with  such  an  ordi- 
nance rightly  enforced. 

The  "Rules  for  Dealing  with  the  Fly  Nuisance,"  circulated  by 
this  committee,  are  as  follows: 

Keep  the  flies  away  from  the  sick,  especially  those  ill  with  contagious 
disease.  Kill  every  fly  that  strays  into  the  sickroom.  His  body  is  covered 
with  disease  germs. 

Do  not  allow  decaying  material  of  any  sort  to  accumulate  on  or  near 
your  premises. 

All  refuse  which  tends  in  any  way  to  fermentation,  such  as  bedding 
straw,  paper  waste,  and  vegetable  matter  should  be  disposed  of  or  covered 
with  lime  or  kerosene  oil. 

Screen  all  food  whether  in  the  house  or  exposed  for  sale. 

Keep  all  receptacles  for  garbage  carefully  covered  and  the  cans  cleaned 
or  sprinkled  with  oil  or  lime. 

Keep  all  stable  manure  in  vault  or  pit,  screened  or  sprinkled  with  lime, 
oil  or  other  cheap  preparations,  such  as  are  sold  by  a  number  of  reliable 
manufacturers. 

See  that  your  sewage  system  is  in  good  order;  that  it  does  not  leak, 
is  up  to  date,  and  not  exposed  to  flies. 

Pour  kerosene  into  the  drains. 

Burn  or  bury  all  table  refuse. 

Screen  all  windows  and  doors,  especially  in  the  kitchen  and  dining-room. 

If  you  see  flies  you  may  be  sure  their  breeding  place  is  in  nearby  filth. 
It  may  be  behind  the  door,  under  the  table  or  in  the  cuspidor. 

If  there  is  no  filth  there  will  be  no  flies. 

If  there  is  a  nuisance  in  the  neighborhood  write  at  once  to  the  health 
department. 

To  Kill  Flies 

The  London  "Lancet,"  the  leading  medical  journal  of  the  world,  says 
that  the  best  and  simplest  fly-killer  is  a  weak  solution  of  formaldehyde  in 
water  (two  teaspoonfuls  to  the  pint).    Place  in  plates  or  saucers  throughout 

(422) 


The  House  Fly  as  a  Carrier  of  Disease  179 

the  house.  Ten  cents'  worth  of  formaldehyde  will  last  an  ordinary  family 
all  summer.  It  has  no  offensive  smell,  is  fatal  to  disease  organisms,  and  is 
practically  non-poisonous  except  to  insects. 

Pyrethrum  powder,  which  may  be  bought  at  any  drug  store,  burned  in 
the  house,  will  also  kill  flies. 

These  rules  go  further  than  the  Indiana  ordinance  in  including 
directions  for  screening  houses  and  food,  and  I  believe  cover  all 
practical  points.  At  any  rate,  with  these  and  the  ordinance  enforced 
in  any  community  I  should  be  willing  to  take  all  the  chances  of 
disease  transmitted  by  flies  that  might  be  afforded  me. 

No  enthusiast  in  the  movement  for  the  extermination  of  the  fly 
should  delude  himself  with  the  belief  that  the  end  he  seeks  is  to  be 
attained  with  ease.  To  be  sure,  the  replacing  of  the  horse  by  the 
automobile  makes  the  city  streets  less  inviting  to  flies ;  and  as  they 
are  not  given  to  flying  more  than  eight  feet  high,  our  sky-scrapers 
are  in  great  part  free  from  them;  nevertheless,  we  cannot  hope 
that  the  mere  advance  of  invention  will  rid  us  of  the  plague.  It 
is  easy  and  simple  to  say,  **If  tlierc  is  no  filth  there  will  be  no 
flies ;"  and  it  is  a  comparatively  simple  thing  so  to  order  one's  own 
house  that  flies  shall  have  no  breeding  place  in  and  immediately 
about  it ;  but  to  insure  the  same  care  on  the  part  of  one's  neighbors 
and  the  general  public  is  the  difficulty.  Hence  the  necessity  for 
organization  to  educate  the  public  to  a  realization  of  fly  dangers 
and  to  build  up  a  body  of  public  opinion  which  will  make  possible 
the  enactment  and  enforcement  of  such  measures  as  I  have  recom- 
mended. In  such  educational  movements  the  newspapers  and  the 
press  generally  will  be  found  able  and  willing  co-workers ;  I  recom- 
mend all  fly-fighters  to  secure  their  powerful  support  at  the  outset 
of  the  campaign.  And  to  any  readers  in  whom  this  paper  may 
have  aroused  an  interest  in  this  very  important  subject  I  promise, 
on  behalf  of  the  Fly-Fighting  Committee  of  the  American  Civic 
Association,  all  the  additional  information  and  assistance  at  its 
command. 


(423) 


THE  MOSQUITO  CAMPAIGN  AS  A  SANITARY  MEASURE 


By  John  B.  Smith,  Sc.D., 

State   Entomologist  of   New  Jersey. 


Insects  as  factors  in  sanitary  work  have  been  very  little  re- 
garded until  recent  years  and,  practically,  only  since  it  was  demon- 
strated that  mosquitoes  of  certain  species  were  necessary  inter- 
mediate agents  in  the  transmission  of  certain  febrile  diseases.  Th-i 
history  of  that  demonstration  has  been  well  written  by  Howard, 
Blanchard,  Theobald  and  others,  and  need  be  only  referred  to  b.ere. 
Since  that  time,  attention  having  been  directed  to  the  class,  certain 
ticks,  lice,  fleas  and  flies  have  been  convicted  as  carriers  or  trans- 
mitters of  a  variety  of  diseases  of  man  and  other  animals,  and  this 
branch  of  entomological  research  has  become  of  the  highest  prac- 
tical importance. 

To  emphasize  the  agency  of  one  of  the  carriers,  Howard  has 
proposed  that  the  common  house  fly  be  hereafter  known  as  the 
typhoid  fly  and,  while  there  are  objections  to  the  name,  it  is  not  in- 
advisable to  follow  him ;  remembering  the  while  that  it  is  really  only 
a  typhoid  fly,  and  not  the  only  species  capable  of  carrying  the  mor- 
bific organism.  Nor  is  its  ability  as  a  carrier  confined  to  typhoid 
or  even  enteric  diseases.  Any  pathological  germ,  microbe,  bacillus 
or  other  creature  capable  of  being  taken  up  and  carried  from  one 
place  to  another  may  be  transported  by  this  omnipresent  pest,  and 
the  comma  and  colon  bacillus  are  equally  liable  to  be  ingested  and 
again  discharged  in  virulent  condition. 

There  are  the  radical  diflferences  between  a  transmitter  and  a 
carrier  of  a  disease  "germ,"  for  a  transmitter  is  usually  agent  for 
one  parasitic  organism  only,  while  a  carrier  may  transiwrt  a  num- 
ber. Stegomyia  calopns  is  a  transmitter  of  yellow  fever  only  and, 
so  far  as  our  knowledge  extends  at  present,  the  only  transmitter  of 
that  disease.  Certain  species  of  Anopheles  are  transmitters  of  the 
various  forms  of  malaria  and,  so  far  as  we  know,  the  only  trans- 
mitters of  those  diseases.  Eliminate  Steiiomyia  and  Anopheles  and 
at  the  same  time  yellow  and  malarial  fevers  have  been  disposed 
of;  but  even  if  every  house  fly  could  be  at  one  blow  destroyed. 

(424) 


The  Mosquito  Campaign  as  a  Sanitary  Measure  i8i 

typhoid,  cholera  and  other  enteric  fevers  would  yet  continue  to 
exist  and  would  even  appear  in  epidemic  form  when  conditions 
favored. 

It  is  matter  of  interest  also  to  note  that  by  far  the  most  im- 
portant of  the  transmitters  of  disease  belong  to  the  order  Diptera 
or  two-winged  flies,  the  most  highly  specialized  of  all  the  insect 
orders,  and  probably  the  most  recent  in  point  of  development.  I 
am  not  unmindful  of  the  fact  that  mites  and  ticks  are  sources  of 
danger  and  agents  in  the  transmission  of  Texas  fever  in  cattle  and 
spotted  fever  in  man ;  but  as  a  general  statement  and  applied  to  the 
true  insects  alone,  the  order  Diptera  contains  the  most  dangerous 
of  all  our  species  from  the  sanitary  standpoint. 

Any  effort  to  lessen  or  altogether  eliminate  any  of  the  mos- 
quito carriers  of  disease  is  therefore  worthy  of  the  support  of  sani- 
tary authorities,  whether  national,  state  or  numicipal.  and  this  fact 
has  been  recognized  to  the  fullest  extent  by  the  I'nited  States  Gov- 
ernment authorities  at  work  in  the  Panama  Canal  Zone. 

A  brief  consideration  of  the  life  cycle  of  mos(iuitoes  is  desir- 
able, to  understand  the  extent  and  variety  of  work  necessary  in 
any  comprehensive  campaign,  for  while  there  are  some  similarities 
there  are  also  many  diflferences  in  habits  and  development.  All 
mosquitoes  are  wrigglers  in  the  larval  stages,  and  all  require  water 
for  development ;  that  is  the  one  feature  identical  in  the  life  history 
of  all  the  species  so  far  as  known  to  me.  But  there  is  the  greatest 
divergence  as  to  the  kind  of  water  preferred  and  in  the  conditions 
under  which  they  occur.  Some  species  breed  only  in  woodland 
pools,  some  only  on  salt  marshes,  some  only  in  tree  holes  filled  witii 
water,  some  only  in  the  small  collections  of  liquid  found  in  pitcher 
plants  and  other  water-storing  plants,  some  onlv  in  clean  water, 
while  a  few  are  specifically  dirty-water  mosquitoes.  In  the  tropics 
the  divergencies  in  breeding  habits  are  still  greater,  but  for  my 
present  purpose  the  consideration  of  species  is  confined  to  the  types 
occurring  in  the  Middle  Atlantic  states  and  immediately  adjacent 
regions. 

It  is  particularly  to  be  noted  in  this  connection  that  the  dirty- 
water  breeders  are  those  most  closely  associated  with  man — Stego- 
tnyia  calopus  and  Cule.v  pipiens  for  instance — and  are  rarely  if  at  all 
to  be  found  far  removed  from  his  settlements.  They  have  specific- 
ally adapted  themselves  to  live  in  association  with  him  and  in  the 

(425) 


1 82  The  Annals  of  the  American  Academy 

liquid  wastes  that  he  produces.  The  larva  of  the  house  mosquito— > 
Culex  pipiens — lives  indoors  and  out,  in  any  receptacle  containing 
water — a  fruit  jar,  a  flush  tank  or  even  an  unused  bowl  of  a  water 
closet,  in  cesspools,  manure  pits,  sewer  catch-basins,  gutters,  etc. 
There  is  no  liquid  so  filthy,  so  it  be  actually  a  liquid,  as  to  daunt  this 
species.  And  here  comes  a  thought  for  those  who  consider  the  house 
mosquito  leniently,  as  something  to  be  philosophically  endured  be- 
cause of  the  trouble  and  expense  of  dealing  with  him  otherwise. 
The  food  of  these  wrigglers  consists  of  the  micro-organisms  found 
in  this  waste  and  foul  water — of  the  specific  and  morbific  organisms 
from  all  the  excreting  organs  of  the  human  and  animal  body,  of 
those  producing  ferments  and  decay  and  of  about  everything  that 
the  sanitarian  deems  most  vile  and  objectionable — and  this  creature, 
so  nourished  and  built  up,  has  been  and  is  allowed  in  our  houses, 
allowed  to  feed  upon  our  blood  and  upon  that  of  our  children, 
allowed  to  puncture  the  skin  and  inject  into  our  veins  the  poisonous 
salivary  secretions  distilled  out  of  all  this  refuse!  Is  it  at  all  won- 
derful that  sometimes  a  mosquito  bite  sets  up  serious  disturbances 
even  where  pathological  organisms  are  not  carried !  Strictly  speak- 
ing, although  it  carries  no  specific  disease,  Ciilex  pipiens  is  a 
greater  nuisance  than  the  malaria  transmitting  Anopheles  because 
of  its  greater  abundance,  its  wider  range,  its  vicious  bite  and  its 
more  persistent  efforts  to  get  indoors  and  into  our  dwellings. 

Now,  while  all  mosquito  larvae  or  wrigglers  are  water  dwellers 
and  feeders  upon  minute  or  other  organisms,  their  method  of  feed- 
ing is  not  identical,  nor  is  the  level  at  which  they  feed  or  the  method 
of  breathing  the  same.  A  very  few  wrigglers  are  carnivorous,  feed- 
ing upon  others  of  their  kind.  All  the  Anopheles  are  top  feeders, 
skimming  spores  and  other  material  that  falls  upon  the  surface,  and 
these  forms  may  exist  in  very  shallow  water,  along  the  grassy  edges 
of  streams  or  pools,  or  in  partially  over-grown  swamps  among  or 
even  over  partially  submerged  leaves,  the  body  resting  parallel  to 
or  upon  the  surface  of  the  water.  These  species  depend  entirely 
upon  atmospheric  air  for  their  supply  of  oxygen,  and  that  is  drawn 
in  through  a  short  tube  at  the  anal  end  of  the  body.  The  species 
of  Ciilex  as  a  rule  feed  upon  organisms  living  beneath  the  surface 
or  even  on  the  bottom,  coming  to  the  surface  only  to  breathe  by 
means  of  a  longer  tube  than  that  of  Anopheles.  They  never  He  on 
the  surface  and  require  deeper  water  than  those  of  the  preceding 

(426) 


The  Mosquito  Campaign  as  a  Sanitary  Measure  183 

type.  A  few  species  have,  besides  the  anal  tube,  tracheal  gills  de- 
veloped at  the  hind  part  of  the  body,  and  these  need  not  necessarily 
come  to  the  surface  to  breathe :  they  are  able  to  and  do  obtain  a  large 
portion  of  their  supply  of  oxygen  directly  from  the  water.  A  very 
few  species,  of  which  Culex  pertnrbans  is  our  only  local  represen- 
tative, are  bottom  feeders  and  get  their  supply  of  air  out  of  large- 
celled  plants.  Here  the  anal  tube  is  modified  into  an  auger-like 
structure  which  is  forced  into  a  plant  stem  or  root,  and  there  the 
insect  rests,  getting  its  oxygen  supply  out  of  the  plant 

Manifestly,  while  we  can  use  oil  to  kill  the  wrigglers  of  those 
types  that  get  their  air  supply  above  the  surface,  we  cannot  so  reach 
those  that  are  not  surface  breathers.  Fortunately  all  our  pestiferous 
forms  except  pertnrbans  are  dependent  upon  atmospheric  air  and 
can  be  reached  with  oil ;  but  where  pertnrbans  is  the  species  in  fault 
none  of  the  ordinary  methods  of  procedure  are  available. 

There  is  a  still  greater  divergence  in  the  egg-laying  habits  of 
the  insects.  The  house  mosquito  and  a  very  few  others  lay  them 
in  a  raft  or  boat  on  the  surface  of  the  water,  and  that  is  the  form 
in  which  they  are  commonly  seen,  because  these  include  the  common, 
annoying  forms.  The  species  of  Anopheles  also  lay  their  eggs  on 
the  surface,  but  singly  or  in  little  groups,  never  bound  together  in 
a  boat  or  raft.  Eggs  so  laid  usually  hatch  within  a  day  or  two; 
but  C.  pertnrbans  is  an  exception  in  this  respect  as  well  as  in  larval 
habit. 

By  far  the  larger  proportion  of  species  do  not  lay  their  eggs 
on  or  in  water  at  all  or,  if  they  do,  the  eggs  do  not  remain  on  the 
surface.  All  of  the  salt  marsh  forms  except  C.  salinarius  and  most 
of  the  woodland  species  lay  their  eggs  in  mud  or  in  moist  depres- 
sions where  water  has  been  and  is  likely  to  be  again.  Such  egg^i 
often  retain  their  vitality  for  long  periods,  measured  not  by  days, 
weeks  or  months,  but  by  years,  and  they  may  be  dried  out  com- 
pletely for  a  long  time  without  losing  the  power  of  development. 
When  circumstances  favor,  the  larvae  hatch  promptly,  so  that  after 
a  year  or  two  of  dormancy  in  the  egg  stage  develop  into  the  adult 
form  within  a  week  or  ten  days. 

So  there  is  great  divergence  in  the  length  of  adult  life,  in  the 
habits  of  the  adult  and  in  the  number  of  broods.  Most  of  the  woods 
mosquitoes  have  only  a  single  brood  annually,  developing  in  early 
spring  from  eggs  that  have  lain  dormant  during  the  winter,  and 

(427) 


184  The  Annals  of  the  American  Academy 

the  adults  from  that  brood  may  and  generally  do  live  until  after 
midsummer,  biting  as  often  as  they  get  a  chance  to  do  so.  Some 
of  these  woodland  forms  never  leave  the  shelter  of  the  trees  even 
in  pursuit  of  food;  but  some  of  them  will  fly  some  distance  out  at 
night.  In  such  cases  settlements  in  or  along  the  edge  of  wood- 
land may  be  troubled  on  piazzas  or  in  open  rooms;  but  the  insects 
rarely  make  any  effort  to  get  indoors  and  do  not  remain.  The  spe- 
cies that  breed  on  the  salt  marshes — except  salinarius — also  winter 
in  the  egg-stage  and  develop  early  in  spring;  but  of  these  there 
may  be  from  four  to  eight  broods  during  the  summer,  depending 
upon  weather  conditions.  These  species  develop  only  after  a  storm 
that  fills  the  marsh  depressions  or  after  an  unusually  high  tide  or 
a  combination  of  the  two.  I^nlike  most  other  mosquitoes  these 
marsh  forms  have  a  peculiar  migratory  instinct  developed.  Within 
a  day  or  two  after  a  heavy  brood  comes  to  maturity,  if  there  comes 
a  warm  quiet  night  with  only  a  moderate  wind,  thousands — yea 
millions  of  the  insects  will  rise  as  if  by  concerted  action  high  in 
air  and  Avill  partially  fly,  partially  drift  for  many  miles  with  the 
wind,  settling  down  over  the  country  many  miles  from  their  point 
of  origin.  I  have  watched  cantator,  one  of  the  salt  marsh  forms 
come  into  a  window  in  Philadelphia  before  midnight,  after  a  flight 
that  could  not  have  been  much  less  than  forty  miles,  and  I  have 
had  reports  of  a  rising  up  of  sollicitans  from  the  marsh  along  the 
Barnegat  shore  and  of  the  presence  of  the  swarm  in  the  pines  early 
next  morning,  where  none  were  the  day  before.  The  arrival  of 
tcrniorhynchus  has  been  actually  noted  at  the  brow  of  the  Palisades 
in  New  Jersey  on  an  east  wind  when  the  nearest  known  breeding 
place  for  the  species  was  at  the  mouth  of  the  Bronx  River  in  New 
York  State.  None  of  the  inland  species  so  far  as  I  know  them  have 
this  migratory  habit  so  well  developed,  though  perturbans  possesses 
it  to  some  extent.  None  of  these  forms  are  really  house  mosquitoes 
in  the  sense  that  they  will  make  special  efforts  to  get  indoors.  They 
will  fly  through  an  open  door  or  window  or  follow  in  a  victim ; 
but  they  are  readily  kept  out  by  even  an  imperfect  screen  and  they 
are  usually  at  least  as  anxious  to  get  out  as  they  were  to  get  in. 
They  never  remain  to  hide  or  to  hibernate. 

The  species  of  Anopheles  hibernate  111  the  adult  stage  and  xk"'^ 
are  house  mosquitoes  in  the  sense  that  they  try  to  get  indoors  a.\r. 
will  remain  there  by  preference  until  the  desire  to  oviposit  d^^velopc. 

(428) 


The  Mosquito  Cavt/^aign  as  a  Sanitary  Measure  185 

They  do  not  breed  by  preference  in  dirty,  and  not  at  all  in  filthy, 
water.  They  frequent  grassy  edges  of  pools,  ponds  or  sluggish 
streams,  and  are  sometimes  found  in  water  barrels,  pails,  tubs  or 
the  like.  They  are  not  so  closely  associated  with  humanity  as  C. 
pipiens,  but  find  its  company  desirable  as  food.  These  species  do 
not  begin  breeding  \try  early  and  are  rarely  seen  in  the  larval 
stage  much  before  midsummer;  but  they  will  continue  to  breed 
until  actual  frost,  and  there  may  be  four  or  even  five  broods  during 
the  season.  Beginning  with  the  latter  part  of  September  some  of 
the  impregnated  females  seek  shelter  in  barns,  cellars,  outhouses, 
in  sheltered  overhangs  among  roots  of  trees  and  begin  their  winter 
dormancy.  This  dormant  population  increases  until  late  October ; 
but  the  specimens  maturing  later  do  not  seem  to  mate,  and  die  off. 
Over  5,000  specimens  of  Anopheles  punctipennis  have  been  taken 
during  the  winter  in  a  single  barn,  and  Anopheles  was  not  a  trouble- 
some form  in  that  vicinity  either.  It  was  simply  the  best  available 
place  for  the  purpose  in  the  neighborhood.  The  species  of  this 
genus  do  not  ordinarily  fly  for  great  distances.  They  seem  to 
require  blood  food  to  mature  their  eggs  and  will  travel  far  enough 
to  find  that.  Half  a  mile  is  well  within  their  compass  and  I  feel 
sure  that  is  not  the  limit;  on  the  other  hand  they  will  under  ordi- 
nary conditions  fly  no  further  than  necessary  and  in  malarial  out- 
breaks a  distance  of  1,000  feet  from  the  breeding  area  for  the 
species  is  rather  unusual,  while  500  feet  is  common. 

The  house  mosquito,  C.  pipiens,  derives  this  name  from  its 
efforts  to  enter  into  our  dewllings  and  its  determination  to  stay 
there  as  long  as  possible.  From  its  breeding  habits  it  is  also 
termed  the  rain-barrel  or  dirty-water  mosquito,  and  it  might  with 
equal  justice  be  called  the  sewer  or  sewage  mosquito.  It  also 
hibernates  in  the  adult  stage,  and  preferably  in  cellars,  where  it 
rests  on  the  side  walls  or  ceilings,  in  dark  and  slightly  damp  places. 
In  very  cold  weather  the  specimens  are  dormant  and  not  easily 
started  into  activity ;  as  it  becomes  warmer  they  fly  ever  more  readily, 
and  in  May  are  ready  to  leave  and  start  breeding.  They  do  not 
bite  during  the  winter  for  that  would  start  development  of  the 
ovaries  and,  unless  the  insect  found  a  chance  to  oviposit,  it  would 
result  in  its  death  before  spring.  Breeding  is  continuous  during 
the  summer  and  the  number  of  broods  depends  only  on  the  supply 
of  dirty  water.    From  tg^  to  adult  requires  only  eight  days,  and 

(429) 


i86  The  Annals  of  the  American  Academy 

a  week  later  the  new  adults  are  ready  to  reproduce  their  kind. 
During  midsummer  when  wrigglers  become  numerous  and  pools 
small,  an  undersized  brood  is  apt  to  develop  and  these  specimens 
find  little  difficulty  in  getting  through  the  ordinary  wire-netting 
screens. 

This  species  will  get  into  houses  if  it  possibly  can,  through 
openings  of  all  kinds  and  has  even  been  accused  of  getting  down 
the  chimney  and  out  through  fire-places.  It  requires  the  closest 
kind  of  care  and  most  persistent  watching  to  exclude  them  and  even 
then  a  few  specimens  manage  to  get  in  during  the  summer  and  the 
cellar  becomes  filled  during  the  winter.  After  a  summer  like  that 
of  1910  a  cellar  population  may  number  hundreds  or  thousands, 
depending  upon  the  ease  of  entry. 

From  what  has  been  said  it  is  apparent  that  the  primary  factor 
upon  which  success  depends  is  a  knowledge  of  the  species  in  fault. 
Knowing  this  we  are  in  position  to  deal  with  the  species  with  a  fair 
prospect  of  success. 

In  suburban  communities  where  any  amount  of  woodland 
remains  and  the  houses  are  more  or  less  surrounded  by  trees,  wood- 
land species  are  apt  to  be  troublesome  early  in  the  season,  and  if 
that  proves  to  be  the  case,  the  breeding  pools  can  be  very  easily 
located  and  abolished.  Where  they  can  be  drained  that  is  the  safest 
and  most  permanent  disposition  to  be  made  of  them.  Where  that 
is  not  possible  the  depressions  may  be  filled  with  leaves,  branches 
or  other  broken  woodland  rubbish  sufficient  to  absorb  the  water  or 
completely  cover  it.  That  will  serve  to  prevent  access  by  the  female 
mosquitoes  and  will  prevent  them  from  laying  eggs.  Where  neither 
draining  nor  filling  is  feasible  or  possible,  the  breeding  area  may 
be  covered  with  oil  as  soon  as  larvae  are  found  which  will  usually 
be  in  April.  As  there  is  only  one  annual  brood  of  these  pests,  one 
treatment  only,  sufficient  to  destroy  all  the  larv?e  then  present,  is 
necessary  to  secure  exemption  for  the  summer. 

As  water  is  necessary  to  enable  the  insects  to  develop,  so  it 
is  only  necessary  for  us  to  locate  the  water  in  which  these  wrig- 
glers breed,  to  enable  us  to  deal  with  them.  And  that  leads  to  the 
statement  that  by  no  means  all  water  areas  are  mosquito  breeders. 
As  a  rule  the  larger  and  deeper  the  pool,  the  less  the  danger. 
Wrigglers  will  not  develop  in  areas  swept  by  the  winds  or  in 
"ripple"  areas.     Nor   can  they  maintain   themselves   in  pools  or 

(430) 


The  Mosquito  Campaign  as  a  Sanitary  Measure  187 

ponds  containing  fish,  provided  the  edges  or  banks  are  sufficiently 
clean  to  permit  the  fish  to  reach  all  portions  of  it.  In  grassy  or 
overgrown  edges  or  areas  larvae  will  breed.  Ponds  or  pools  cov- 
ered with  duck-weed  are  safe  and  so  are  pools  filled  with  the 
stringy  Spirogyra.  Deep  cold  swamps  breed  no  mosquito  larvae 
nor  do  dense  overgrown  cat-tail  areas.  Many  campaigns  have 
failed  because  all  the  efforts  were  made  against  and  work  done  on 
areas  where  no  breeding  occurred  while  the  places  where  the  species 
really  developed  were  unnoticed.  Flowing  streams  are  not  often 
sources  of  danger,  especially  where  they  contain  fish ;  but  they  may 
become  so  in  a  droughty  period  or  when  the  water  is  low  and  the 
flow  is  interrupted. 

Where  Anopheles  is  in  fault  the  larger  water  bodies  must  be 
examined  and  if  an  overgrown  pond  or  a  sluggish  stream  is  foimd 
in  fault,  it  will  mean  cleaning  up  to  enable  fish  to  operate,  or  clean- 
ing out,  to  improve  the  flow  of  the  stream. 

Where  perturbans  is  in  fault  each  case  must  be  dealt  with 
according  to  local  conditions  and  no  general  rule  can  be  laid  down. 
If  the  salt-marsh  species  is  at  fault  an  inland  community  may 
find  itself  absolutely  helpless.  There  are  hundreds  of  square  miles 
of  mosquito  ridden  territory  in  New  Jersey  where  not  a  single  mos- 
quito breeds  and  where  the  residents  can  only  suffer  or  join  in  aid 
of  the  state  fight. 

Where  the  ordinary  house-mosquito  is  in  fault  it  means  close, 
sanitary,  house-to-house  inspection  and  in  this  campaign  every 
householder  should  join.  Water  barrels  and  cisterns  should  have 
every  opening  closely  screened  with  close-meshed  wire  or  a  double 
netting.  Cess-pools  should  be  sealed  or,  if  ventilated,  the  ventilat- 
ing pipe  should  have  a  double  wire  netting.  Every  depression 
capable  of  holding  water  should  be  filled,  or  periodically  oiled,  and 
every  sewer  catch-basin  or  settling  basin  should  be  oiled  period- 
ically during  the  summer.  Once  every  ten  days  is  sufficient  in 
periods  of  drought,  and  within  a  week  after  every  rain  a  coating 
of  oil  should  be  put  on.  To  enumerate  all  the  places  that  should 
be  looked  after  is  impossible,  and  should  be  unnecessary  when  we 
have  learned  that  every  pool,  puddle,  or  receptacle  containing  water 
may  be  dangerous. 

In  a  very  wet  season  there  is  danger  because  then  many  places 
where  water  ordinarily  evaporates  promptlv,  may  be  kept  filled 

(431) 


i88  The  Annals  of  the  American  Academy 

long  enough  to  develop  the  insects.  But  in  such  a  season  the  sewers 
and  sewer  catch-hasins  rarely  become  sources  of  serious  trouble. 
In  a  very  dry  se£.son  the  sewer  basins  become  the  source  of  most 
intensive  breeding;,  and  small  streams  carrying  off  surface  water 
become  reduced  to  breeding  puddles.  Of  the  two  the  droughty 
season  breeds  more  city  and  town  mosquitoes  than  the  rainy  one. 

The  campaign  should  begin  in  winter,  against  the  hibernating 
species  in  houses.  I  have  tried  many  sorts  of  fumigants  and  more 
have  been  tried  by  others;  but  the  only  reliable  destructive  mate- 
rial that  I  have  found  is  Mim's  Culicide.  That  is  a  mixture  of 
carbolic  acid  crystals  and  gum  camphor,  using  equal  parts,  by 
weight.  Liquefy  the  carbolic  acid  crystals  by  a  gentle  heat,  break 
up  the  gum  camphor  into  small  pieces  and  pour  the  liquid  acid 
slowly  over  the  camphor.  The  acid  will  dissolve  the  camphor  com- 
pletely and  the  resulting  liquid  is  permanent  and  only  slightly 
volatile  at  ordinary  temperatures.  It  volatilizes  rapidly,  however, 
in  a  shallow  dish  over  the  flame  of  an  alcohol  or  other  lamp  and 
the  vapor  is  death  to  flies  and  mosquitoes.  Three  ounces  will  suf- 
fice for  I, GOO  cubic  feet  in  a  tightly  closed  room,  and  it  will  require 
about  half  an  hour  to  evaporate  that  amount.  The  vapor  is  not 
poisonous  to  man,  is  not  destructive  to  metals  or  fabrics  and  is 
disinfectant  in  quality.  In  a  large  cellar  there  should  be  fumigants 
at  several  points  to  secure  equal  distribution  of  the  vapor  and  equal 
effect  throughout  the  cellar.  The  material  is  not  explosive,  but  is 
inflammable  and  should  be  used  with  that  fact  in  mind. 

In  New  Jersey  the  sanitary  position  of  the  mosquito  question 
is  determined  in  the  general  health  law  of  the  state  which  defines 
among  the  nuisances  "waters  in  which  mosquito  larvae  breed,"  and 
over  these  local  boards  of  health  have  the  same  jurisdiction  as  over 
any  other  nuisances,  with  absolute  power  to  abate. 

The  dual  nature  of  the  problem  is  strikingly  illustrated  in 
this  state  with  its  long  coast  line  bordered  by  salt  marshes  of  rela- 
tively enormous  extent.  More  than  half  the  area  of  the  state  was 
periodically  overwhelmed  by  flights  from  these  marshes  and  per- 
haps ninety  per  cent  of  all  the  mosquitoes  in  South  Jersey  were 
bred  on  the  salt  marshes.  It  was  manifestly  useless  to  preach  local 
campaigns  here  where,  even  across  the  two  ranges  of  the  Wasatch 
Mountains,  no  local  campaign  could  promise  exemption  from  trouble. 
Nor  could  the  thinly  settled  townships  in  which  these  salt  marshes 

(432) 


The  Mosquito  Campaign  as  a  Sanitary  Measure  189 

occurred,  be  reasonably  asked  to  abate  the  nuisances  for  the  benefit 
of  the  more  densely  settled  localities  inland.  There  was  only  one 
authority  fit  to  cope  with  the  problem  and  that  was  the  state  itself. 
The  value  of  the  New  Jersey  seashore  for  summer  resorts  ofifered 
an  additional  inducement  for  state  interference,  and  $350,000  was 
appropriated  for  draining  the  salt  marshes,  of  which  $83,500  has 
been  made  actually  available.  It  seems  like  a  terrific  task  to  under- 
take the  extermination  of  mosquitoes  from  an  area  of  over  four 
hundred  square  miles  of  desolation;  nevertheless  the  work  is  in 
progress  and  up  to  the  present  time  the  cost  has  been  within  the 
estimates  upon  which  the  original  appropriation  was  based,  not- 
withstanding the  fact  that  the  cost  of  labor  has  been  materially 
increased.  Over  four  million  lineal  feet  of  ditches  have  been  dug 
and  over  25.000  acres  of  salt  marsh  have  been  made  approximately 
mosquito  proof.  The  character  of  the  problem  has  been  changed 
in  the  more  northern  localities,  and  it  has  become  a  local  one  in 
which  the  local  municipalities  are  now  concerning  themselves  and 
may  count  on  success. 

On  the  salt  marshes  the  areas  are  first  carefully  surveyed  to 
determine  where  breeding  places  exist.  The  aid  of  the  local  board 
of  health  is  then  invoked  and  notice  is  given  to  marsh  owners 
making  them  acquainted  with  the  facts  and  the  law.  They  are 
given  an  opportunity  to  abate  in  their  own  way  if  they  will,  but  if 
they  do  not — as  generally  happens — the  entire  area  is  drained  in 
one  block,  under  a  general  plan,  and  the  work  is  paid  for  by  the 
state.  The  matter  is  not  really  so  serious  as  it  looks  at  first  blush, 
because  the  marshes  are  peaty  in  character  and  the  water  runs  out 
easily.  The  ditches  are  thirty  inches  deep,  usually  ten  inches  in 
width,  and  placed  about  200  feet  apart  in  ordinarily  bad  areas. 
Some  very  rotten  marsh  is  more  thoroughly  ditched  and  sound 
level  marsh  is  not  interfered  with  at  all.  These  ditches  through 
the  turf  stand  indefinitely  and,  owing  to  their  narrowness  and  depth, 
never  grow  up  from  the  bottom.  If  not  interfered  with  they  will 
drain  the  marsh  of  surface  water  within  forty-eight  hours  after 
being  flooded  by  storm  or  tide,  and  will  thus  prevent  the  maturing 
of  such  larvae  as  may  hatch.  There  is  no  pretense  of  reclaiming 
the  marsh  for  agricultural  purposes,  and  all  the  ditches  connect 
with  tidewater  so  that  the  character  of  the  land  is  not  changed. 
But  the  character  of  the  grass  is  affected  by  the  drainage  and 

(433) 


IQO  The  Annals  of  the  American  Academy 

it  becomes  different  in  type  and  better,  giving  also  much  larger 
crops. 

The  work  has  been  in  progress  for  only  four  years  and  has 
just  begun  to  show  effects,  but  as  the  area  treated  is  enlarged  and 
the  benefits  become  evident  over  a  greater  region  it  is  hoped  that 
more  co-operation  will  be  secured  and  more  rapid  progress  made. 
The  additional  comfort  secured  where  mosquitoes  are  absent  has, 
in  some  localities,  already  brought  crowded  houses  and  induced 
building  so  that  as  a  mere  investment  the  work  will  eventually  pay 
heavily.  In  the  additional  benefits  secured  by  the  person  seeking 
rest  and  health  at  the  seashore,  the  return  cannot  be  measured  by 
money  values. 

In  the  local  campaign,  the  state  organization  acts  in  an 
advisory  capacity  only.  It  will  make  surveys,  inspections  and 
reports  for  any  municipality  desiring  the  same,  and  it  will  advise 
as  to  what  should  be  done.  Experiments  are  made  with  oils  and 
other  materials  suggested  or  recommended  for  the  control  of  the 
insects  in  any  stage,  and  annual  reports  are  made  and  published, 
showing  the  progress  of  the  work  and  the  information  obtained. 

Recently  an  organization  has  been  formed  by  representatives  of 
boards  of  health  from  a  group  of  counties  centering  about  Newark, 
Jersey  City  and  Elizabeth,  and  for  the  benefit  of  these  an  inspector 
will  be  maintained  merely  to  give  notice  to  the  local  authorities 
of  developments  requiring  action  to  control  or  destroy  breeding 
places.  Efforts  will  be  made  to  secure  permanent  drainage  or  filling 
of  the  larger  swampy  areas,  the  diversion  of  small  brooks  carrying 
surface  waters  into  trunk  sewers,  and  the  elimination  of  all  the 
small  breeding  areas  by  orders  of  the  local  boards  of  health. 

No  one  who  has  not  had  actual  experience  can  realize  in  how 
many  different  kinds  of  places  mosquito  wrigglers  can  be  found, 
especially  in  an  active  manufacturing  city.  Wherever  water  is 
stored  in  tanks  for  any  purpose  they  have  been  found:  in  a  pickle 
factory  a  lot  of  seventy-five  hogsheads  stored  in  a  yard  were  partly 
filled  with  water  to  prevent  shrinkage,  and  thousands  of  wrigglers 
were  in  each,  supplying  the  neighborhood  for  squares  round  about 
with  mosquitoes.  In  fire-buckets,  even  in  halls  of  hotels  they  are 
not  uncommon,  and  in  the  thousand  and  one  different  sorts  of  con- 
tainers of  the  hundreds  of  factories,  there  is  almost  unlimited  oppor- 
tunity for  mosquito  propagation.     Even  in  dwellings  a  neglected 

(434) 


The  Mosquito  Campaign  as  a  Sanitary  Measure  191 

aquarium  has  been  found  infested,  the  flush  tank  of  a  rarely  used 
closet  and  the  exposed  trap  of  a  shower  bath  serving  as  further 
examples  of  wriggler  adaptation. 

The  sanitary  officer  in  charge  of  a  municipal  mosquito  cam- 
paign has  no  light  task  and  his  first  effort,  after  educating  himself, 
must  be  to  educate  his  constituency  to  co-operate  with  him. 


X435) 


CLEAN  MILK  AND  PUBLIC  HEALTH 


By  Jesse  D.  Burks,  Ph.D., 
Director  of  the  Bureau  of  Municipal  Research  of   Philadelphia. 


Behind  its  veil  of  opaque  whiteness,  every  quart  of  milk 
hides  a  potential  peril  to  the  public  health.  To  the  unaided  senses, 
unwholesome  or  dangerous  milk  may  present  exactly  the  same 
appearance  as  the  purest  and  safest  supply  obtainable.  Until 
the  horizon  of  intelligence  and  imagination  has  been  extended 
by  science,  therefore,  it  is  exceedingly  difficult  to  appreciate  the 
serious  need  for  being  constantly  on  guard  against  a  menace 
so  intangible  and  so  insidious. 

Even  before  bacteriological  and  chemical  research  had  dis- 
closed the  hidden  causes  pf  disease,  milk  was  known  to  constitute 
a  very  important  danger  to  health,  and  crude  methods  of  im- 
proving the  "keeping"  qualities  of  milk  by  heating  and  refrig- 
erating had  been  developed.  The  rapid  growth  of  cities,  how- 
ever, and  the  consequent  ever-increasing  separation  of  the  dairy 
farms  where  milk  is  produced  from  a  vast  number  of  the  homes 
where  it  is  consumed,  has  introduced  a  new  and  very  serious  difficulty 
into  the  problem  of  providing  city  consumers  with  a  safe  milk 
supply.  Whereas,  formerly,  it  was  possible  to  distribute  milk 
to  consumers  within  a  few  hours  after  it  was  drawn,  it  is  now 
frequently  necessary  to  transport  a  supply  from  very  great  dis- 
tances and  thus  separate  by  twenty-four,  thirty-six,  or  even 
forty-eight  hours  the  time  when  milk  is  drawn,  from  the  time 
when  it  is  delivered  to  consumers.  When  we  reflect  that  milk 
is  probably  the  most  generally  used  article  of  food ;  that  it  fur- 
nishes an  almost  ideal  culture  medium  for  very  many  forms  of 
disease  germs ;  that  it  may  very  easily  become  infected  at  any 
one  of  the  many  stages  of  its  progress  from  cow  to  consumer; 
and  that,  at  favorable  temperatures,  the  number  of  disease  germs 
it  contains  will  increase  with  almost  incredible  rapidity,  the  sig- 
nificance of  the  time  element,  as  well  as  of  care  in  handling  milk, 
will  at  once  be  apparent. 

With  the  growth  of  scientific  knowledge  regarding  specific 

(436) 


Clean  Milk  and  Public  Health  193 

dangers  from  infected  milk,  and  with  the  increasing  difficulty 
of  obtaining  a  safe  supply,  there  has  come  a  more  intelligent 
appreciation,  on  the  part  of  laymen  and  of  health  officials,  of 
the  need  for  a  comprehensive  and  effective  plan  for  controlling 
a  community's  milk  supply,  especially  in  the  case  of  large  cities. 
There  is  probably  no  factor  in  a  public  health  program  that  is 
being  more  actively  and  more  persistently  studied  or  that  gives 
promise  of  more  immediate  and  more  positive  results.  Clean 
water,  clean  air,  clean  food,  clean  streets,  clean  houses,  clean 
clothing,  and  clean  bodies  are  the  indispensable  elements  in 
modern  preventive  hygiene ;  and  among  these,  if  we  measure 
importance  by  the  potential  effect  upon  disease  and  death  rate, 
clean  milk  must  be  assigned  high,  if  not  first,  rank. 

Careful  estimates  place  the  average  annual  consumption  of 
milk  in  the  cities  of  the  United  States  at  twenty-three  gallons 
per  capita,  some  authorities  estimating  the  quantity  as  high  as 
one-eighth  of  the  entire  food  consumption  of  the  urban  and 
suburban  population.  On  this  basis  alone,  the  importance  to 
the  public  health  of  protecting  the  milk  supply  from  contamina- 
tion and  deterioration  needs  no  argument.  In  view  of  the  further 
fact  that  milk  forms  the  chief  and,  in  many  cases,  the  sole  ele- 
ment in  the  diet  of  the  sick,  the  aged,  and  the  infant  members 
of  society,  the  necessity  for  precautionary  measures  receives 
further  emphasis.  The  technical  difficulty  of  testing  milk  as  to 
adulteration  and  infection,  the  great  distances  and  varied  sources 
from  which  city  supplies  are  obtained,  and  the  large  cost  in- 
volved, make  it  wholly  impracticable  for  individual  consumers 
to  discover  by  direct  investigation  the  quality  of  milk  served 
by  dealers.  It  is  clear,  therefore,  that  for  reasons  of  economy 
and  efficiency  of  service,  the  inspection  and  regulation  of  a  com- 
munity's milk  supply  is  properly  a  community  function,  to  be 
performed  by  a  governmental  agency  having  adequate  legal  pow- 
ers, and  the  organization  and  administrative  methods  necessary 
to  make  its  powers  effective. 

Stated  in  the  simplest  terms,  the  control  of  a  milk  supply 
has  two  main  aspects,  the  first  having  to  do  with  chemical  con- 
stituents which  is  related  chiefly  to  the  food  or  nutritive  value 
of  milk ;  the  second  with  bacteriological  content,  which  is  re- 
lated chiefly  to  the  pathological  or  hygienic  effects. 

(437) 


194  The  Annals  of  the  American  Academy 

On  the  side  of  chemical  content,  a  few  simple  and  well- 
dejfined  standards  concerning  adulteration  and  the  use  of  pre- 
servatives have  been  clearly  established,  though  not  even  these 
have  been  everywhere  accepted  as  a  basis  for  practical  control. 
It  is  known  that  the  use  of  preservatives  is  both  unnecessary  and 
harmful.  It  is  unnecessary,  because  milk  produced  under  proper 
conditions  and  handled  with  care  will  "keep"  long  enough  to 
permit  of  transportation  and  distribution  within  necessary  and 
reasonable  limits  of  time.  It  is  harmful,  because  the  addition  of 
salicylic  acid,  formaldehyde,  benzoic  acid  and  other  chemicals 
used  as  preservatives  either  impair  the  digestibility  of  milk  or 
injure  the  digestive  organs  of  the  consumer,  especially  in  the 
case  of  young  infants,  whose  membranes  are  extremely  sensitive 
to  such  irritants.  Although  the  use  of  such  preservatives  is 
prohibited  by  the  national  pure  food  law  of  1906,  and  by  the 
laws  of  many  States,  there  is  still  a  wide  sale  for  these  chemicals 
under  such  trade  names  as  "Iceline"  and  "Freezine."  It  is  not 
uncommon,  especially  in  the  summer,  for  a  dairyman  to  add 
one  of  these  preservatives ;  the  wholesale  dealer,  in  ignorance  of 
this  fact,  adding  a  second  treatment;  and  the  retail  dealer,  again 
in  ignorance  of  what  has  been  done,  adding  a  third  preservative 
to  the  same  milk.  Such  practice  is,  of  course,  little  short  of 
criminal.  It  can  be  detected  only  by  chemical  tests  and  can 
be  prevented  only  by  constant  inspection  and  vigorous  prosecu- 
tion of  offenders. 

Adulteration  is  still  practiced  to  a  very  considerable  extent, 
the  most  common  methods  being  the  addition  of  water  or  skim- 
med milk  and  the  removal  of  cream.  The  addition  of  chalk  and 
other  materials  for  thickening  and  coloring  milk  is  probably 
practiced  to  a  very  limited  extent.  Adulteration  of  any  kind, 
without  the  knowledge  of  the  consumer,  is  unwarranted  and 
fraudulent.  The  addition  of  water  not  only  alters  the  nutritive 
value  of  the  milk,  but  is  often  a  source  of  pollution ;  the  intro- 
duction, even  in  minute  quantities,  of  water  infected  with  typhoid 
or  other  water-borne  germs  being  sufficient  to  start  a  wide- 
spread epidemic.  The  removal  of  cream  materially  aflfects  the 
food  value  of  milk  and  in  this  way  may  result  in  serious  con- 
sequences to  infants  and  others  dependent  upon  a  milk  diet. 

(438) 


Clean  Milk  and  Public  Health  195 

Gross  adulteration  is  readily  tested  either  by  chemical  or 
by  physical  (lactometer)  tests.  Inasmuch  as  milk  varies  con- 
siderably in  the  relative  amount  of  water  and  of  solid  contents 
which  it  normally  contains,  however,  it  is  impossible,  within 
certain  limits,  to  determine  by  inspection  whether  or  not  water 
has  been  added.  The  usual  method  of  controlling  water  adul- 
teration is  to  fix  a  minimum  standard  of  solid  contents  and  to 
exclude  or  destroy  milk  not  conforming  to  this  standard.  It  is 
readily  seen,  however,  that  milk  containing  milk  solids  in  excess 
of  the  standard  may  be  manipulated  by  adulteration  or  by  re- 
moval of  cream  so  long  as  the  legal  standard  is  maintained. 

It  is  a  common  error  to  assume  that  milk  found  to  meet  a 
legal  standard  as  to  solid  contents  may  thereby  be  known  as 
milk  of  high  quality.  As  a  matter  of  fact,  when  milk  just  reaches 
the  usual  legal  standards,  it  is  prima  facie  inferior  in  quality, 
being  of  the  lowest  grade  permitted.  There  has  been  a  tendency, 
recently,  to  lower  legal  standards  so  that  milk  from  certain 
breeds  of  cow,  notably  the  Holstein,  which  is  normally  deficient 
in  milk  solids,  might  come  within  the  prescribed  limits.  Such 
legislation  might  be  characterized  as  itself  a  species  of  adultera- 
tion, placing,  as  it  does,  a  premium  upon  low-grade  milk  and 
making  it  possible  for  an  unscrupulous  dealer  to  impair  the  food 
value  of  milk  normally  good,  by  the  addition  of  water  or  the 
removal  of  cream,  without  making  himself  liable  under  the  law. 

It  is  true  that  the  minimum  limit  must  not  be  placed  so  high 
as  to  exclude  the  milk  from  too  many  herds.  Aside  from  the 
danger  of  infection,  however,  there  seems  to  be  little  diflference 
between  adding  water  after  milking,  by  means  of  a  dipper,  or 
before  milking,  through  the  natural  processes  of  secretion.  The 
rational  remedy  for  this  difficulty  appears  to  be  the  grading  of 
milk  on  the  basis  of  its  food  value  and  the  fixing  of  prices  for 
the  several  grades,  so  that  both  dealers  and  consumers  may  reap 
the  advantage  of  maintaining  high  standards.  Such  a  plan  re- 
quires that  consumers  be  so  educated  as  to  appreciate  the  dif- 
ference between  high-grade  and  low-grade  milk,  and  to  demand 
satisfactory  evidence  as  to  the  quality  of  milk  received. 

The  second  main  aspect  of  the  problem  of  controlling  a  milk 
supply  has  to  do  with  the  bacteriological  content  of  milk,  which 

(439) 


196  The  Annals  of  the  American  Academy 

is  the  side  of  the  problem  most  intimately  related  to  the  public 
health. 

Next  to  polluted  water,  there  is  probably  no  more  prolific" 
source  of  infectious  disease  than  contaminated  milk.  The  danger 
from  infected  water  has  been  widely  recognized  and  methods  of 
protection  by  filtration  and  by  other  means  have  been  so  thor- 
oughly studied  and  so  well  developed  that  many  communities 
have  practically  eliminated  water-borne  epidemics.  In  such  com- 
munities, as  well  as  in  those  where  typhoid  is  still  distributed 
through  the  water  pipes,  polluted  milk  continues,  without  ef- 
fective check,  to  play  its  part  in  causing  periodic  epidemics  of 
typhoid,  scarlet  fever,  diphtheria,  diarrhea  and  other  infectious 
diseases. 

In  a  recent  bulletin  (No.  56),  the  Public  Health  and  Marine- 
Hospital  Service  of  the  United  States  gives  a  tabular  summary 
of  500  epidemics  in  which  there  is  conclusive  evidence  that  milk 
was  the  carrier  of  typhoid,  scarlet  fever,  diphtheria  and  septic 
sore  throat.  In  each  case  the  circumstances  of  the  outbreak  are 
described,  together  with  the  evidence  that  milk  was  the  source 
of  the  disease,  the  manner  in  which  the  milk  was  infected,  the 
number  of  persons  affected,  the  number  of  deaths,  and  the  number 
of  persons  supplied  with  milk  from  the  dairy  to  which  the  disease 
was  traced. 

The  facts  presented  in  this  summary  show  that  a  typical 
milk  epidemic  is  explosive  in  its  outbreak,  the  infection  being 
carried  to  all  users  of  a  given  supply  at  practically  the  same  time, 
thus  causing  a  relatively  large  number  of  them  to  develop  the 
disease  simultaneously.  The  disease  in  such  cases  follows  a  milk 
route  so  closely  that  a  map  of  the  route  may  frequently  be  out- 
lined by  merely  charting  the  cases  of  the  disease  as  they  are 
reported.  It  is  found  that  the  homes  of  the  well-to-do  are  often 
attacked  in  greater  proportion  than  others,  owing  to  the  fact 
that  families  with  larger  incomes  commonly  drink  more  milk 
than  those  with  smaller  resources;  the  latter  using  milk  mainly 
in  tea  or  coffee  and  in  food  preparations  that  are  cooked.  Sim- 
ilarly, it  is  thought  that  women  and  children,  being  larger  con- 
sumers of  milk  than  men,  are  more  frequently  affected  by  milk- 
borne  epidemics.  The  500  milk  epidemics  described  in  these 
tables  are  only  a  few  of  those  concerning  which  definite  records 

(440) 


Clean  Milk  and  Public  Health  197 

are  available.  The  immense  number  for  which  such  records  are 
not  available  can  only  be  surmised. 

The  precise  relation  of  milk  to  the  spread  of  tuberculosis 
has  been  a  matter  of  uncertainty.  The  announcement  made  by 
Koch,  about  ten  years  ago,  that  bovine  tuberculosis  is  very 
slightly,  if  at  all,  transmissible  to  human  beings,  seemed  at  the 
time  to  dispose  of  a  very  serious  problem.  Subsequent  investiga- 
tion by  a  large  number  of  observers,  how^ever,  has  removed  all 
doubt  as  to  the  fact  of  transmission  of  the  disease  from  cows  to 
human  beings.  One  of  the  most  active  of  these  observers,  von 
Behring,  goes  so  far  as  to  state  that  the  use  of  cow's  milk  as 
food  for  infants  is  the  principal  cause  of  human  tuberculosis. 
More  conservative  authorities  estimate  the  peicentage  of  the 
disease  in  man  due  to  bovine  origin  as  low  as  three  per  cent. 
Taken  with  the  fact  that  not  less  than  160,000  deaths  from  tuber- 
culosis occur  annually  in  the  United  States,  even  this  low  esti- 
mate shows  that  cow's  milk  infected  with  tuberculosis  presents 
a  very  grave  menace  to  the  public  health. 

There  is  no  doubt  that,  among  children  under  five  years  of 
age,  bovine  tuberculosis  is  relatively  a  much  larger  cause  of  the 
disease  than  among  adults.  Recent  observations  in  two  institu- 
tions for  the  care  of  children  in  New  York  strongly  support  the 
conclusion  that  about  one-half  of  those  children  who  develop 
tuberculosis  and  who  are  fed  upon  raw  cow's  milk  contract  the 
disease  from  infected  milk.  Since  about  one  in  fourteen  deaths 
from  tuberculosis  in  the  United  States,  for  the  year  1905,  were 
among  children  under  five  years  old,  it  is  probable  that  6000  deaths 
among  these  children  were  chargeable  directly  to  infected  milk. 
The  number  contracting  the  disease  within  this  age  period  and 
dying  later  cannot,  of  course,  be  given,  but  must  be  very  large. 

Reliable  facts  concerning  the  prevalence  of  tuberculosis 
among  herds  are  difficult  to  obtain.  Apparently  the  number 
varies  greatly  with  climate,  location,  and  the  care  given  to  the 
cows.  In  certain  districts,  autopsies  show  as  high  as  60  per 
cent,  of  the  cattle  to  be  tuberculous;  in  others  the  number  is  so 
low  as  to  be  almost  negligible.  Taking  the  country  at  large,  it 
seems  likely  that  not  less  than  one  in  three  of  the  dairy  herds 
and  not  less  than  one  in  five  of  all  dairy  cows  are  tuberculous. 
Considering  the  fact  that  milk  from  a  single  tuberculous  cow 

(441) 


198 


The  Annals  of  the  American  Academy 


may  be  mixed  with  and  thus  contaminate  the  milk  from  a  large 
number  of  cows  not  affected,  and  that  tubercle  bacilli  contained 
in  the  feces  of  infected  cattle  may  contaminate  milk  from  non- 
tuberculous  cows,  the  spread  of  tuberculosis  through  a  milk 
supply  is  seen  to  be  a  matter  calling  for  vigorous  and  constant 
action. 

Important  as  it  undoubtedly  is  to  safeguard  the  milk  supply 
of  a  community  as  a  means  of  controlling  the  ravages  of  typhoid, 
scarlet  fever,  diphtheria  and  tuberculosis,  it  is  even  more  im- 
portant as  a  means  of  reducing  the  enormous  mortality  among 
infants  which  is  chargeable,  in  very  large  measure  to  gastro- 
enteritis (diarrhea),  the  dominant  cause  of  which  is  unclean  milk 
and  ignorant  feeding. 

The  number  of  deaths  among  infants  under  one  year  old  in 
the  United  States,  for  the  year  1909,  was  approximately  250,000, 
which  is  about  one-fifth  of  the  total  number  of  deaths  of  all  ages. 
Of  this  startling  number  of  infant  deaths,  it  is  estimated  that 
almost  two-thirds  were  preventable;  at  least  one-quarter  being 
caused  by  enteritis  alone — a  shocking  sacrifice  to  ignorance  and 
carelessness. 

The  stupendous  proportions  of  this  annual  waste  of  infant 
life  will  be  more  clearly  appreciated  when  it  is  compared  with 
the  160,000  annual  deaths  from  tuberculosis  and  the  20,000  from 
typhoid,  which  are  the  occasion  of  such  general  agitation.  The 
infant  deaths  from  enteritis  alone — attributable  almost  wholly 
to  milk  infection — were  about  three  times  as  numerous  as  the 
deaths  of  all  ages  from  typhoid,  which  is  itself  very  largely  a 
milk-borne  disease. 

In  an  article  appearing  in  the  American  Journal  of  Medical 
Science  (Vol.  CXXXII,  pp.  811-835),  Harrington  gives  the 
following  statement  regarding  the  infantile  death  rate  per  thou- 
sand infants  in  the  States  constituting  the  registration  area  of 
this  country.  The  figures  are  based  upon  the  report  of  the 
Bureau  of  the  Census  for  1900. 


District  of  Columbia   274.5 

Rhode   Island   197.9 

Massachusetts   177-5 

New  Hampshire  172.0 

New  Jersey  167.4 


New  York  159.8 

Connecticut    156.8 

Maine  144.1 

Vermont    122.1 

Michigan   121.1 


(442) 


Clean  Milk  and  Public  Health 


199 


The  cities  show  an  even  higher  infant  mortality  rate.  One 
hundred  and  six  towns  and  cities  had  a  rate  of  175  or  more  per 
thousand,  nine  of  these  having  a  rate  exceeding  300  per  thousand  ; 
the  highest  rate,  that  of  Charleston,  S.  C,  being  419  per  thou- 
sand. Eight  of  the  largest  cities  had  infant  mortality  rates  as 
follows : 


Washington,  D.  C 274.5 

Baltimore,  Md 235.  i 

New  Orleans,  La 229.2 

Philadelphia,  Pa 197.2 


Brooklyn,  N.  Y 197.2 

Boston,  Mass i94-i 

Borough  of  Manhattan  190.9 

New  York,  N.  Y 189.4 


In  a  chapter  on  "Infant  Feeding,"  in  the  bulletin  before  cited, 
Dr.  Schereschewsky  quotes  records  showing  that  in  France, 
during  the  five-year  period  1892-1897,  385  infant  deaths  in  every 
1000  were  due  to  gastro-intestinal  diseases ;  the  death  rate  from 
this  cause  in  certain  cities  running  as  high  as  700  per  thousand 
infant  deaths.  Records  are  given  for  42  German  cities,  also, 
showing  infantile  death  rates  ranging  from  127  to  271  per  thou- 
sand births,  the  average  for  the  forty-two  cities  being  198.  The 
per  cent,  of  these  deaths  due  to  diarrhea  varied  from  seventeen 
to  fifty-four  per  cent,  the  average  being  forty-four  per  cent.  These 
figures  are  interesting  as  showing  the  relative  mortality  in  Ameri- 
can cities  and  as  confirming  the  conclusion  that  a  great  propor- 
tion of  infant  deaths  are  due  to  the  single  preventable  cause  of 
diarrhea. 

The  fact  that  the  number  of  deaths  from  diarrhea  invariably 
increases  enormously  during  the  summer  months,  when  it  is  most 
difficult  to  prevent  the  multiplication  of  bacilli  in  milk,  is  further 
evidence  of  the  need  for  more  eflfective  control  over  milk  infec- 
tion. Schereschewsky  states  that  in  the  city  of  Leipzig,  whose 
percentage  (54.9)  of  deaths  from  diarrhea  is  the  highest  among 
the  German  cities,  the  infant  mortality  in  February  was  131  per 
thousand,  of  which  thirty-seven  were  from  diarrheal  diseases. 
In  August  the  infant  death  rate  had  increased  to  570,  of  which 
430  (75.6  per  cent.)  were  from  enteritis.  It  is  a  general  observa- 
tion that  the  great  wave  of  infant  mortality  during  the  summer 
months  is  accounted  for  almost  wholly  by  the  increase  in  in- 
testinal diseases. 

The  part  played  by  infected  milk  in  this  summer  mortality 

(443) 


200  The  Annals  of  the  American  Academy 

is  strikingly  shown  by  the  contrast  between  the  death  rate 
among  breast-fed  and  that  among  artificially  fed  babies.  Plan- 
chon  (quoted  by  Schereschewsky)  shows  that  while  the  di- 
arrheal death  rate  of  breast-fed  infants  in  Paris  varies  from 
a  minimum  of  two  per  thousand  in  winter  to  a  maximum  of 
twenty  per  thousand  during  the  summer,  the  rate  for  artificially 
fed  infants  varies  from  twelve  per  thousand  in  winter  to  158  in 
summer.  Harrington's  figures,  for  a  five-year  period  in  Berlin, 
show  similarly  that,  in  cases  where  the  mode  of  feeding  was 
known,  about  ninety  per  cent,  of  infant  deaths  were  among  arti- 
ficially fed  babies,  and  ten  per  cent  among  the  breast-fed. 

Such  figures  as  are  available  for  American  cities  fully  confirm 
the  great  disadvantage  of  artificial  feeding.  In  a  recent  paper 
presented  at  a  conference  called  by  the  New  York  Milk  Com- 
mittee, for  example.  Dr.  William  H.  Park  gave  the  following  ob- 
servations as  to  the  efifect  cf  dififerent  types  of  feeding  upon  in- 
fant mortality  and  morbidity : 

Number  of  Infants 

Kind  of  Feeding                                   Observed  Died  Sick 

Cheap   store   milk — heated    79  15  20 

Condensed  milk    70  14  14 

Good  bottled  milk   98  9  29 

Good  milk — modified  and  bottled   145  4  24 

Certified   milk    12  o  o 

Breast  milk    31  0  7 

Figures  might  easily  be  multiplied  to  emphasize  the  advan- 
tage of  breast  feeding.  The  fact  remains,  however,  that  the  in- 
creasing number  of  women  entering  industrial  pursuits,  and  other 
influences  incident  to  modern  urban  life,  are  causing  a  distinct 
decline  in  the  practice  of  breast  feeding.  Deplorable  as  this 
tendency  may  be  conceded  to  be,  it  is  not  likely  to  be  checked 
so  long  as  economic  forces  continue  to  operate  as  at  present. 
The  problem  of  preventing  the  great  annual  needless  mortality 
among  infants  is,  therefore,  a  problem  of  providing  cow's  milk 
free  from  infection  and  from  injurious  preservatives,  and  of  edu- 
cating mothers  and  caretakers  to  prepare  and  administer  such 
milk  in  a  manner  suited  to  the  nutritive  requirements  of  infants. 

The  chief  sources  of  contamination  to  be  considered  in  formu- 
lating and  carrying  into  efifect  a  program  for  safeguarding  a  com- 
munity's milk  supply  are :    First,  human  beings  having  infectious 

(444) 


Clean  Milk  and  Public  Health  201 

diseases  and  those  carrying  infection  on  their  persons ;  second, 
diseased  cattle;  third,  polluted  water;  and  fourth,  bacteria- 
ladened  dust  and  dirt. 

It  is  obvious  that  no  person  affected  with  typhoid,  tubercu- 
losis, scarlet  fever  or  other  infectious  diseases,  or  who  has  con- 
tact with  persons  so  affected,  can  handle  milk  or  vessels  to  be 
used  as  milk  containers  without  subjecting  the  milk  to  serious 
danger  of  contamination.  It  is  not  so  commonly  understood, 
however,  that  convalescents  and  persons  who  have  apparently 
recovered  entirely  from  certain  diseases  may  continue  to  dis- 
charge bacilli  for  weeks,  for  years,  and  even  for  the  whole  of 
their  lives.  Notably  in  the  case  of  typhoid,  persons  who  have 
been  in  contact  with  the  sick  or  with  bacillus  carriers  may  be- 
come centers  of  typhoid  infection  without  themselves  developing 
the  disease.  It  has  been  estimated  that  there  are  about  as  many 
typhoid  carriers  at  any  given  time  as  there  are  actual  cases  of 
typhoid.  When  to  these  are  added  the  individuals  in  the  early 
stages  of  the  disease,  who  may  continue  to  handle  milk  so  long 
as  they  are  physically  able  to  do  so,  and  others  who  may  handle 
milk  throughout  the  entire  course  of  a  mild  form  of  the  disease, 
it  will  be  seen  that  there  is  reason  for  the  utmost  vigilance  in 
this  direction. 

Of  the  diseases  of  cattle  which  render  milk  unfit  for  human 
consumi)tion,  tuberculosis  is  undoubtedly  the  most  important,  as 
well  as  the  most  prevalent.  Where  the  cow's  udder  is  tuber- 
culous, the  danger  of  infection  through  the  milk  is  generally 
recognized  by  students  of  the  subject.  It  appears  to  have  been 
clearly  proven,  also,  that  the  tubercle  bacillus  is  sometimes  found 
in  the  milk  of  cows  whose  udders  are  not  specifically  involved, 
especially  where  the  disease  has  reached  an  advanced  stage,  but 
also  in  cases  where  the  disease  can  be  diagnosed  only  by  means 
of  the  tuberculin  test.  As  the  milk  from  an  entire  herd  is  com- 
monly mixed  for  transportation,  it  is  clear  that  the  presence  of 
a  few  tuberculous  cows  in  a  herd  may  infect  the  entire  product 
and  render  it  unsafe  for  consumption. 

Cows  affected  with  gastro-enteritis,  garget,  cowpox,  ulcers, 
and  other  septic  or  febrile  conditions  frequently  produce  milk 
infected  with  pus-producing  bacilli,  certain  of  which  are  known 
to  cause  enteritis.     Moreover,  even  when  no  active  pathogenic 

(445) 


202  The  Annals  of  the  American  Academy 

organisms  are  found  in  milk,  poisonous  properties  resulting  from 
disease  and  from  unwholesome  food  and  water  may  be  present 
in  sufficient  quantity  to  constitute  real  danger  to  persons  taking 
such  milk. 

Polluted  water,  even  where  it  is  not  used  as  an  adulterant, 
is  a  frequent  source  of  milk  contamination.  Wells  and  streams 
are  often  so  located  that  the  drainage  from  barn  yard  or  privy 
vault  readily  finds  its  way  into  them.  Decaying  animal  matter 
and  excreta  from  patients  having  typhoid  and  other  infectious 
diseases  are  often  disposed  of  in  such  a  way  as  to  subject  the 
water  to  contamination.  Milk  pails,  cans,  bottles  and  dairy 
equipment  of  other  kinds,  when  washed  with  water  so  polluted, 
unless  afterwards  sterilized  with  boiling  water  or  steam,  may 
become  the  means  of  infecting  the  entire  product  of  a  dairy  farm. 

At  every  step  in  the  handling  of  milk,  from  the  cow  to  the 
consumer,  there  is  constant  danger  of  infection  from  dust  and 
dirt.  Hair  and  dirt  from  the  cow's  flanks  and  udder;  manure 
and  dust  from  the  floor,  walls  and  ceiling  of  the  stable  or  milk- 
house  ;  minute  particles  from  the  hands  and  clothing  of  the 
milker  or  handler  of  milk ;  disease-ladened  dirt  and  filth  on  every 
hand,  in  dairy,  milk  shop,  milk  wagon,  kitchen  and  refrig- 
erator— all  these  contain  the  virulent  seeds  that  need  only  be 
scattered  by  air  or  water  or  flies  or  the  hand  of  man  to  produce 
a  certain  harvest  of  misery,  disease  and  death.  Modern  aseptic 
surgery  has  taught  the  world  the  vital  meaning  of  absolute 
cleanliness.  The  lesson  is  directly  applicable  to  the  problem  of 
obtaining  an  adequate  supply  of  clean  milk.  When  we  come 
to  apply  scientific  method  to  the  study  and  control  of  milk  infec- 
tion with  the  same  intelligence  and  thoroughness  that  have  been 
shown  in  surgical  practice,  we  shall  eliminate  quite  as  much 
needless  suffering  and  waste  of  human  life  as  was  done  away 
with  forty  years  ago,  when  the  old  skull-and-cross-bones  surgery 
came  to  a  sudden  end. 

Meantime,  our  septic  method  of  producing  and  handling  milk 
may  be  expected  to  continue  until  producers,  distributors  and 
consumers  are  ready  to  face  the  facts  and,  at  whatever  cost, 
to  support  the  practical  measures  necessary  to  produce  clean 
milk  at  the  dairy  farm  and  to  keep  it  clean  all  the  way  to  the 
consumer.    A  comprehensive  program  of  this  kind  will  involve 

(446) 


Clean  Milk  and  Public  Health  203 

the  isolation  and  often  the  sacrifice  of  diseased  cattle.  It  will 
mean  eflfective  inspection  of  cattle,  milk  handlers,  barn  yard, 
water  supply,  stable,  cattle,  feed,  dairy  equipment,  methods  of 
milking  and  handling  milk,  transportation  equipment  and  meth- 
ods, sanitary  conditions  of  city  milk  plants,  of  bottling  works, 
of  milk  shops,  and  of  milk  wagons,  and  methods  of  caring  for 
and  handling  milk  in  the  homes.  It  will  require  the  acceptance 
and  enforcement  of  sanitary  standards  at  every  point  where  milk 
and  dairy  products  are  produced  or  handled ;  of  a  temperature 
standard  so  low  that  the  few  bacteria  that  will  inevitably  reach 
all  milk  shall  have  no  opportunity  to  multiply ;  of  a  standard  of 
bacterial  content  sufficiently  low  to  exclude  milk  dangerous  to 
health ;  and  of  a  chemical  standard  so  rigid  as  to  prevent  the 
sale  of  milk  that  is  in  any  way  adulterated  or  that  is  unduly 
low  in  nutritive  value.  The  plan  will  doubtless  require  also  that 
milk,  ice-cream,  butter  and  other  dairy  products  be  scientifically 
graded,  according  to  quality ;  that  they  be  so  labeled  as  to  in- 
dicate accurately  their  food  value  and  degree  of  purity ;  and  that 
prices  be  graded  to  agree  with  quality. 

The  program,  furthermore,  will  call  for  an  inspection  service 
having  adequate  legal  powers,  eflfective  supervision,  and  a  staflF 
of  appropriate  size  and  technical  qualifications.  The  function  of 
the  inspection  service  will  be  not  merely  to  ascertain  facts  for 
the  purpose  of  locating  defects  and  conducting  prosecutions,  but 
for  the  more  important  constructive  purpose  of  educating  pro- 
ducers, dealers  and  consumers  as  to  the  best  methods  for  over- 
coming difficulties,  for  avoiding  dangers,  and  for  obtaining,  with 
minimum  cost  and  maximum  satisfaction,  a  supply  of  milk  that 
shall  be  safe  and  wholesome.  The  final  and  most  eflfective  factor 
in  the  program  will  be  an  informed,  alert  and  exacting  public, 
which  will  demand  facts  and  discount  unsupported  opinions ; 
which  will  insist  that,  day  by  day  and  hour  by  hour,  such  a  record 
of  work  performed  and  results  accomplished  shall  be  kept  by 
every  producer,  distributor  and  inspector  of  milk  as  will  fix  re- 
sponsibility for  results ;  and  which  will  mete  out,  with  even- 
handed  justice,  the  appropriate  reward  of  fidelity  or  dishonesty, 
efficiency  or  incompetence. 

Hardly  more  than  a  beginning  has  been  made  in  this  country 
toward  the  development  of  such  a  program.    A  few  States  have 

(447) 


204  ^^^^  Annals  of  the  American  Academy 

made  some  provision  for  dairy  inspection,  but  this  is  generally 
limited  to  the  examination  of  herds  for  diseased  cattle,  with 
occasional  attempts  at  sanitary  inspection  of  dairy  farms.  The 
State  service  is  so  inadequate  that  most  large  cities  find  it  neces- 
sary to  maintain  their  own  inspection  service.  The  reasonable 
division  of  functions  would  appear  to  be  for  the  States  to  assume 
responsibility  for  conditions  on  the  dairy  farms,  and  the  cities 
to  control  conditions  incident  to  the  distribution  of  milk  within 
their  own  borders.  This  would  avoid  the  duplication  of  inspec- 
tion by  cities  drawing  their  supplies  from  the  same  territory  and 
would  make  it  impossible  for  a  dairyman,  when  his  milk  is  ex- 
cluded from  one  city,  to  proceed  at  once  to  market  his  product 
in  another  city  whose  standards  are  less  stringent  or  less  rig- 
orously enforced.  Local  and  state  regulation  is  to  some  extent 
supplemented  by  federal  inspection  of  milk  and  other  dairy 
products  entering  into  interstate  commerce.  An  extension  and 
strengthening  of  the  federal  service  would  do  much  to  improve 
the  milk  of  a  number  of  large  cities  which  draw  upon  neighbor- 
ing States  for  their  supply. 

In  view  of  the  numerous  difficulties  involved  and  the  delays 
likely  to  attend  a  completely  satisfactory  solution  of  the  milk 
problem,  many  persons  are  concerning  themselves  chiefly  with 
expedients  for  solving  at  once  certain  of  the  difficulties  and  for 
reducing  so  far  as  possible  the  ill  effects  of  milk  produced  under 
existing  conditions.  Temperature  standards  of  60  degrees 
Fahrenheit,  or  lower,  have  been  established  in  some  cities,  with 
a  view  to  preventing  the  rapid  growth  of  bacteria  and  thus  re- 
ducing the  danger  of  serious  infection.  With  similar  purpose, 
standards  have  been  adopted  which  exclude  milk  showing  a 
bacterial  count  exceeding  100,000,  500,000  or  1,000,000  per  cubic 
centimeter.  Standards  of  11.5,  12  or  13  per  cent,  of  milk  solids 
and  3  to  3.5  per  cent,  of  butter  fat  have  somewhat  generally 
been  established  as  a  means  of  preventing  adulteration.  Infant 
milk  stations,  under  both  public  and  private  management,  have 
been  established  for  the  purpose  of  supplying  clean  milk  either 
in  its  natural  state  or  sterilized  and  specially  modified  to  meet 
the  requirements  of  infants  of  various  ages.  A  model  municipal 
dairy  farm  has  been  operated  by  at  least  one  city  for  the  purpose 
of  setting  a  high  standard    for    private    dairymen.      Complete 

(448) 


Clean  Milk  and  Public  Health  205 

municipal  ownership  and  operation  of  the  dairy  industry  have  been 
advocated,  but  not  yet  realized ;  while  the  commissioner  of  health 
of  Chicago  advocates  the  novel  plan  of  bringing  into  the  cities  a 
sufficient  number  of  cows  to  supply  all  artificially  fed  infants  with 
milk  less  than  twelve  hours  old  at  the  time  it  is  consumed,  and 
of  making  it  legally  obligatory  to  use  only  such  milk  for  the 
feeding  of  babies. 

Most  important  of  the  proposed  expedients  is  pasteurization, 
which,  in  its  most  approved  form,  consists  in  the  heating  of  milk 
to  a  temperature  of  140  degrees  Fahrenheit,  maintaining  this 
temperature  for  twenty  minutes,  and  then  reducing  the  tempera- 
ture rapidly  to  50  degrees  Fahrenheit.  This  process,  it  has  been 
determined,  will  kill  most  pathogenic  bacteria  found  in  milk, 
including  the  bacilli  causing  typhoid,  diphtheria  and  enteritis. 
The  conclusion  seems  warranted  also  that  careful  pasteurization 
does  not  greatly,  if  at  all,  impair  the  general  nutritive  value  of 
milk.  The  effect  of  pasteurization  upon  the  various  soluble  fer- 
ments contained  in  milk  is  still  doubtful,  though  it  has  been  found 
that  a  temperature  only  slightly  above  140  degrees  Fahrenheit 
will  weaken  or  destroy  the  activity  of  some  of  them.  The  functions 
of  the  ferments  themselves  are  not  fully  understood,  though  they 
are  probably  related  in  a  subtle  way  to  the  digestive  requirements 
of  the  new-bom.  If,  as  seems  likely,  the  specific  character  of  the 
ferments  accounts  in  great  measure  for  the  advantage  of  maternal 
over  artificial  feeding,  the  importance  of  more  exact  knowledge 
concerning  the  way  in  which  they  are  affected  by  various  tempera- 
tures and  periods  of  heating  is  evident. 

Even  the  advocates  of  pasteurization  generally  regard  the 
process  only  as  a  valuable  protective  measure  that  may  lessen  the 
injurious  effects  of  stale,  warm,  dirty  and  infected  milk,  but 
should  not  be  permitted  to  interfere  with  efforts  to  promote  care 
and  cleanliness  in  every  possible  way  in  the  production  and 
handling  of  milk.  Pasteurization  certainly  does  not  in  any  way 
improve  the  food  value  of  milk  and,  by  impairing  the  activity 
of  certain  ferments,  may  seriously  affect  its  adaptation  to  very 
young  infants.  It  destroys  the  acid-forming  bacteria  of  milk 
and  interferes  with  one  of  the  surest  evidences  by  which  stale 
milk  may  be  recognized,  allowing  certain  putrefactive  processes 
of  dangerous  character  to  continue  without  the  restraining  in- 

(449) 


2o6  The  Annals  of  the  American  Academy 

fluences  exerted  by  the  lactic  acid  organisms  in  raw  milk,  and 
without  the  knowledge  of  the  consumer.  Certain  poisonous 
bacterial  products,  furthermore,  are  not  destroyed  by  pasteuriza- 
tion. It  will  be  seen,  therefore,  that  the  practice  of  pasteurization 
is  not  to  be  considered  too  favorably,  nor  accepted  as  a  final  solu- 
tion of  the  problem  of  safe  milk,  and  that,  in  the  interest  of  public 
health,  it  must  be  closely  supervised  by  the  proper  authorities. 

The  problem  of  clean  milk  is  to  be  solved,  not  by  uninformed 
discussion,  nor  by  the  emotional  clamor  of  indignant  consumers, 
nor  by  the  good  intentions  of  producers,  dealers,  or  public  of- 
ficials, nor  by  unenforced  legal  provisions.  It  is  to  be  solved, 
as  all  other  important  problems  of  social  welfare  are  to  be  solved, 
by  scientific  inquiry  as  to  the  facts  involved;  by  the  intelligent 
formulation  of  a  comprehensive  program  for  constructive  work ; 
by  efficient  co-operation  on  the  part  of  producers,  transportation 
companies,  dealers,  housewives,  health  officials,  private  social 
agencies ;  and  by  an  informed,  active  and  exacting  citizenship. 


(450) 


VENTILATION  AND  PUBLIC  HEALTH 


By  D.  D.  Kimball, 

Of  Richard  D.  Kimball  Company,  Mechanical  and  Electrical  Engineers, 

New  York. 


Importance  of  Ventilation 

Air  is  more  essential  to  life  than  food,  good  air  is  as  essential 
as  good  food,  and  plenty  of  air  has  the  same  merit  as  plenty  of 
food.  Unlike  food  air  cannot  be  had  in  too  great  quantities,  and 
an  inexhaustible  supply  of  pure  air  is  always  available.  Being 
invisible  and  unfelt  we  give  it  no  thought,  and  thus  we  have  come 
to  give  little  or  no  heed  to  its  condition.  That  air  quality  has  a  definite 
relation  to  comfort  and  health  is  never  denied,  but  that  means  must 
always  be  provided  to  assure  proper  quality  of  air  in  our  habita- 
tions still  fails  to  find  general  assent ;  in  other  words,  ventilation, 
artificial  or  natural,  as  a  means  of  providing  fresh  air,  is  still  denied 
proper  recognition.  This  may  in  part  be  due  to  the  mistaken  idea 
largely  prevailing  that  artificial  ventilation  can  do  for  health  and 
comfort  all  that  nature's  boundless  resources  can  do,  whereas  ven- 
tilation at  its  best  is  but  an  attempt  to  approach  within  doors,  as 
near  as  may  be,  nature's  outdoor  conditions. 

Ventilation  would  make  far  greater  headway  if  the  public  did 
but  realize  how  closely  allied  ventilation  is  to  individual  health. 
In  but  few  of  the  relations  of  life  are  we  free  from  contact  with  the 
public.  Whether  it  be  in  our  homes  with  our  guests,  with  our  chil- 
dren in  the  schools,  traveling  in  street  cars,  railway  cars  or  boats,  at 
the  opera,  concert  or  church,  with  the  sick  in  the  hospitals,  or  with 
the  workers  in  the  factories  and  stores,  we  are  brought  so  inti- 
mately into  contact  with  the  public  that  the  health  of  any  part 
thereof  has  a  definite  bearing  on  the  health  of  the  whole. 

Ventilation  is  closely  connected  with  cleanliness.  Few  of  us 
would  care  to  put  on  underclothing  immediately  taken  from  another 
person,  bathe  in  water  used  by  another,  or  put  into  our  mouths 
articles  of  food  or  drink  taken  from  another's  mouth,  yet  we  take 
into  our  lungs  with  but  little  or  no  hesitation  air  containing  that 

(451) 


2o8  The  Annals  of  the  American  Academy 

which  has  but  just  come  from  other  people's  mouths  and  huigs  or 
from  close  contact  with  their  bodies  and  soiled  clothing. 

Experiments  of  Buchner,  Flugge  and  others  have  shown  that 
tubercle  bacilli  and  other  organisms  are  sprayed  through  a  room 
from  the  mouth,  for  a  distance  of  many  feet  and  over  wide  areas, 
when  men  talk  or  cough.  In  case  of  influenza,  conditions  in  rail- 
way and  other  cars,  churches  and  living  rooms,  all  may  be  infected 
who  are  not  immune. 

The  public  is  just  beginning  to  learn  of  the  wonderful  results 
obtained  in  hospital  work  with  the  introduction  of  outdoor  work 
and  wards,  but  does  not  yet  recognize  that  the  nearer  indoor 
conditions  in  hospitals  are  made  to  approach  outdoor  conditions 
by  means  of  the  most  ample  ventilation  the  better  will  be  the  results. 
When  one  considers  that  there  are  3,000,000  persons  sick  in  the 
United  States,  and  that  the  percentage  of  cures  is  increased,  and 
the  average  length  of  illness  is  decreased  by  ventilation,  the  public 
importance  of  pure  air  becomes  evident. 

The  benefit  of  plenty  of  fresh  air  is  strikingly  seen  in  open- 
air  treament  of  tuberculosis.  Patients  well  advanced  in  the  disease, 
who  for  months  or  even  years  have  spent  their  time  bundled  up 
indoors,  sitting  over  stoves  or  registers,  afraid  of  a  breath  of 
cool  air,  and  who  under  this  regime  cough  continually,  sleep  poorly 
and  have  no  appetite,  after  being  required  to  stay  in  the  open  air  for 
twenty-four  hours  each  day,  and  to  sleep  in  tents  or  open  shacks,  in 
a  week's  time  cease  the  constant  cough,  sleep  and  eat  well,  put  on 
flesh  and  look  like  diflferent  creatures.  Outdoor  treatment  of  pneu- 
monia, anaemia,  nervous  and  other  diseases  is  equally  beneficial. 

Probably  no  place  in  which  people  gather  is  the  need  of  ven- 
tilation as  a  protection  to  the  public  greater  than  in  the  factory, 
store  and  mercantile  establishment,  nevertheless  the  vast  majority 
of  these  are  utterly  devoid  of  ventilation  of  any  kind;  indeed,  as 
examples  of  badly  ventilated  habitations,  they  are  supreme.  Persons 
in  charge  of  factories  know  they  would  be  blamed  were  employees 
to  complain  that  they  had  taken  cold  from  open  windows,  while 
they  are  not  held  responsible  for  sickness  due  to  vitiated  air  and 
overheating.  The  ample  protection  of  health  and  life  in  the  indus- 
tries is  a  matter  of  humanitarian  obligation  on  the  part  of  the 
employer  and  the  public,  as  well  as  a  question  of  self-interest  on  the 
part  of  the   employee.     Ventilation    cannot  properly  be   regarded 

(452) 


Ventilation  and  Public  Health  209 

as  a  high-priced  luxury  to  be  enjoyed  by  the  privileged  few,  but 
should  rather  be  regarded  as  a  priceless  benefit  to  be  enjoyed  by 
all.  No  investment  yields  larger  returns  than  that  required  for 
ventilation. 

The  Problem  of  Ventilation 

Ventilation  is  the  process  of  supplying  fresh  air  and  removing 
so  far  as  possible  the  vitiated  air.  The  air  supply  must  be  clean 
and  free  from  dust,  must  be  of  the  proper  temperature  and  humidity, 
sufficient  quantity  of  air  must  be  secured  by  proper  air  movement 
without  injurious  drafts;  and  poisonous  gases  like  carbonic  oxide 
from  heating  or  lighting  apparatus  must  be  prevented.  Air  must 
be  Supplied  without  loss  of  its  freshness. 

Air  is  the  medium  for  carrying  oxygen  into  the  lungs,  its  office 
being  to  oxidize  the  excretions  from  the  blood  vessels  therein. 
Oxygen  is  thus  the  element  of  the  air  that  is  of  the  greatest 
importance  to  human  beings.  It  is  essential  in  both  heating  and 
ventilating  work,  being  the  active  element  in  combustion  and  in 
the  similar  processes  which  go  on  .within  the  human  lungs  where 
it  acts  upon  the  carbon  and  impurities  in  the  blood,  forming  the 
chemical  compounds  which  are  thrown  off  during  respiration. 

Fresh  air  is  taken  into  the  lungs  containing  approximately  21 
per  cent  oxygen,  78  per  cent  nitrogen,  .04  per  cent  carbonic  acid, 
and  .01  per  cent  water  vapor.  The  process  of  respiration  changes 
the  composition  of  the  air  breathed  to  approximately  16  per  cent 
oxygen,  75  per  cent  nitrogen,  4  per  cent  carbonic  acid  and  5  per 
cent  water  vapor.  Oxygen  is  reduced  in  amount  while  the  carbonic 
acid  and  water  vapor  are  largely  increased.  Oxygen  is  utilized  for 
body  building,  and  carbonic  acid  and  water  vapor  are  the  products 
given  off  during  respiration. 

Neither  water  vapor  nor  the  carbonic  acid  due  to  respiration 
is  injurious ;  but  as  an  increase  of  carbonic  acid  in  the  air  of  an 
occupied  apartment  is  usually  accompanied  by  a  decrease  in  the 
amount  of  oxygen  and  an  increase  of  water  vapor,  the  percentage 
of  carbonic  acid  is  an  index  of  the  quality  of  the  air. 

Apparently  it  is  not  altogether  the  chemistry  of  the  air,  but  its 
temperature,  humidity,  motion  and  possibly  other  physical  proper- 
ties unknown,  which  are  the  attractive  features  of  outdoor  air.  It 
is  becoming  to  be   generally  believed   that   when   air  contains   a 

(453) 


2IO  The  Annals  of  the  American  Academy 

normal  proportion  of  oxygen,  its  temperature  and  humidity  are 
of  greater  importance  than  the  absence  of  carbonic  acid. 

The  over-heating  of  dwellings  and  public  buildings  should  "be 
avoided.  The  proper  control  of  the  temperature  is  not  alone  con- 
ducive to  health  and  comfort  but  means  a  substantial  saving  in  fuel. 
Headaches,  dizziness,  sickness,  etc.,  are  often  symptoms  of  heat 
retention  due  chiefly  to  highroom  temperature  and  humidity.  It  is 
not  uncommon  to  find  houses,  offices,  etc.,  in  which  the  temperature 
sometimes  reaches  80°,  and  yet  the  occupants  can  hardly  be  con- 
vinced that  the  temperature  is  high,  because  of  the  fact  that  the 
percentage  of  moisture  in  the  air  is  very  low.  Few  of  us  realize 
the  intimate  relation  of  temperature  and  humidity,  and  many  people 
do  not  appreciate  that  water  vapor  is  as  much  a  part  of  the  a'ir  as 
oxygen. 

The  relative  humidity  of  outdoor  air  at  other  times  than  dur- 
ing storms  varies  from  50  per  cent  to  80  per  cent,  and  in  the  most 
arid  desert  is  rarely  as  low  as  30  per  cent,  while  a  relative  humidity 
of  48  per  cent,  that  of  Denver,  is  considered  very  dry. 

Air  at  zero  and  50  per  ,cent  relative  humidity  contains  less 
than  a  quarter  of  a  grain  of  moisture  per  cubic  foot.  The  same 
air  warmed  to  70°  without  the  addition  of  moisture  would  have 
a  relative  humidity  of  but  3  per  cent.  Its  absorptive  capacity  is, 
therefore,  immensely  increased. 

If  air  on  a  day  on  which  the  outside  temperature  is  zero  and 
the  relative  humidity  50  per  cent  be  passed  through  a  furnace,  and 
raised  to  70°,  the  relative  humidity  of  the  air  in  a  house  will  be  10 
per  cent  to  20  per  cent  or  dryer  than  the  air  of  the  driest  desert 
known.  If  a  room  at  68°  is  not  warm  enough  for  a  healthy  person 
we  may  be  sure  it  is  because  the  relative  humidity  is  too  low, 
except  in  rare  cases  when  the  humidity  is  so  high,  i.  e.  80  per  cent 
or  above,  that  the  moisture  in  the  air  rapidly  absorbs  heat  from 
the  body,  under  which  conditions  one  may  complain  of  chilliness 
even  with  high  temperature.  It  is  unscientific  and  unsatisfactory 
to  determine  upon  a  temperature  for  comfort  without  regard  to 
humidity. 

With  outdoor  weather  conditions  of  zero,  and  50  per  cent  rela- 
tive humidity,  the  proper  ventilation  of  a  schoolroom  containing 
forty  pupils  will  require  the  addition  to  the  air  of  approximately 
thirty-eight  pounds,  about  five  gallons,  of  water  each  hour,  requiring 

(454) 


Ventilation  and  Public  Health  211 

for  its  evaporation,  the  consumption  of  approximately  five  pounds  of 
coal  per  hour.  The  fact  that  there  are  very  few  schools  with  means 
of  humidification  is  less  an  argument  to  be  used  against  such  pro- 
vision than  an  impeachment  of  the  prevailing  methods  of  school- 
room ventilation. 

The  remarkable  avidity  of  dry  warm  air  for  moisture  causes 
it  to  extract  moisture  from  everything  with  which  it  comes  into 
contact,  and  when  the  tissues  and  delicate  membranes  of  the  respi- 
ratory tract  are  subjected  to  this  drying  process  a  large  increase 
of  work  is  placed  upon  the  mucous  glands.  This  unnatural  stimu- 
lation may  result  in  an  enlargement  of  the  gland  tissues,  just  as 
constant  exercise  increases  the  size  of  any  part  of  the  animal  organ- 
ism. The  membrane  itself  may  become  thickened  and  harsh,  and 
the  surface  prepared  for  the  reception  of  disease  germs,  which 
tend  to  develop  under  exposure  to  the  constantly  changing  per- 
centages of  humidity.  Not  alone  are  the  throat  and  lungs  affected ; 
the  tongue,  lips  and  skin  become  feverish  and  parched,  the  eyes 
redden  and  smart,  the  ears  are  unnaturally  dried ;  catarrh  is  induced, 
or  is  aggravated  if  already  existing.  In  the  case  of  children  pre- 
disposed to  lung  diseases  a  serious  hacking  cough  is  apt  to  result. 
Overdry  air  causes  headaches,  robs  all  of  vitality,  and  in  every  way 
lowers  the  vital  powers.  Generally  speaking  dry  air  is  an  excitant, 
sometimes  causing  sleeplessness  and  irritability,  while  moist  air 
seems  balmy  and  has  a  soothing  effect  whicji  tends  to  produce 
restfulness  and  sleep. 

A  proper  relative  humidity  lessens  the  evaporation  from  the 
surface  of  the  body  and  thus  the  body  remains  warmer,  conse- 
quently with  air  of  a  relative  humidity  of  50  per  cent  to  60  per  cent, 
it  is  both  possible  and  comfortable  to  lower  the  temperature  of  the 
house  to  65°,  schools  to  62°,  and  the  temperature  of  public  build- 
ings may  be  lowered  similarly. 

The  idea  that  a  lessening  of  the  room  temperature  when  rais- 
ing the  relative  humidity  will  result  in  economy  in  heating  is  in 
error.  It  takes  much  more  heat  (which  means  fuel)  to  evaporate 
the  water  required  to  increase  the  relative  humidity  than  to  heat  the 
air  5"  or  10°. 

The  children  in  the  schools  with  a  proper  relative  humidity 
are  much  healthier  and  consequently  are  able  to  think  and  remember 
better.    Capable  officials  have  determined  that  the  working  capacity 

(455) 


212  The  Annals  of  the  American  Academy 

of  factory  operatives  is  definitely  increased  in  air  of  proper  relative 
humidity. 

It  is  a  sad  commentary  on  our  modern  civilization  that  we 
wilfully  allow  the  health  of  the  school  children  and  the  public  gen- 
erally to  suffer  for  the  lack  of  proper  moisture  while  the  manu- 
facturer whose  commercialism  tells  him  that  relative  humidity  is 
important  to  the  success  or  profits  of  his  manufacturing  process 
will  provide  necessary  humidifying  apparatus. 

Dust  is  another  serious  problem  in  ventilation.  Many  ven- 
tilating systems  are  worse  than  useless  because  the  air  is  taken 
in  at  or  below  the  street  level  or  from  other  dust-contaminated 
sources,  and  is  passed  into  the  building  without  filtration,  the  result 
being  that  the  last  state  of  the  building  is  worse  than  the  first. 

There  are  two  phases  to  the  dust  question :  the  mechanical  effect 
of  dust,  and  its  gennicidal  properties.  Careful  investigations  have 
demonstrated  that  dust,  especially  street  dust,  is  heavily  laden  with 
germs,  the  majority  of  which  are  harmless  but  others  are  of  a  most 
serious  nature.  Carried  into  the  respiratory  tract  they  lodge  in 
soil  splendidly  adapted  to  the  propagation  of  germ  life.  Dust  is 
a  serious  irritant,  and  when  drawn  into  the  nasal  passages,  throat 
and  lungs,  may  cause  irritation  and  even  abrasions.  The  mortality 
from  consumption  is  known  to  be  very  much  greater  among  persons 
employed  in  the  so-called  dusty  trades  than  among  those  who  work 
in  the  open  air,  or  under  otherwise  more  sanitary  and  favorable 
conditions  affecting  health  and  life.  Some  trades  involve  processes 
in  which  dust,  fumes,  vapors,  odors,  excessive  heat  and  poisons  are 
produced  which  are  really  injurious  and  which  are  properly  removed 
in  but  rare  cases. 

Windows  and  doors  may  be  depended  upon  for  ventilation  of 
buildings  only  when  it  is  evident  that  a  sufficient  current  of  air 
passes  through  to  give  thorough  ventilation  and  without  causing 
drafts  which  strike  and  chill  a  portion  of  the  body  of  those  who 
are  insufficiently  clad.  If  sufficient  air  is  not  naturally  passing 
through  the  windows  and  doors,  air  movement  should  be  assured 
by  mechanical  means. 

Drafts  and  cold  are  too  commonly  associated  with  "colds." 
Breezes  which  bathe  the  whole  body  not  only  bring  unlimited  sup- 
plies of  the  purest  air  but  have  a  tonic  eflFect.  Cold  air  does  not 
cause   "colds."     Arctic  explorers   rarely,   if  ever,  have   colds.     It 

(456) 


Ventilation  and  Public  Health  213 

is  during  the  winter  months  that  outdoor  treatments  are  the  most 
successful.  The  places  most  to  be  feared  are  not  out  of  doors, 
in  hallways  and  in  fresh  air  currents,  but  in  vitiated  atmospheres 
such  as  are  common  to  ill-ventilated  schools,  theatres,  churches, 
railway  cars  and  wherever  overcrowding*  occurs.  Drafts  of  this 
vitiated  air  are  a  menace.  Dust,  leading  to  disease  infection,  is  more 
frequently  the  cause  of  colds  than  fresh  air  drafts.  Unquestionably 
there  exists  a  misunderstanding  of  the  nature  and  effect  of  fresh 
air  drafts  and  a  fear  often  akin  to  fright.  A  weakened  vitality, 
harboring  disease  germs,  may  be  wonderfully  toned  up  by  frequent 
and  generous  drafts  of  fresh  air,  or  to  an  equal  extent  may  be 
injured  by  a  lesser  movement  of  vitiated  air.  A  hot,  shut-up  house 
is  little  more  than  a  hot  house  for  the  propagation  of  bacilli  and 
disease  germs.  Out-of-door  life  in  plenty,  ample  exercise,  and 
thorough  ventilation  of  indoors  may  be  depended  upon  to  give  prac- 
tical immunity  from  drafts  as  commonly  known. 

While  the  use  of  natural  ventilation  is  to  be  encouraged  in 
every  way  possible,  it  may  not  be  depended  upon  in  our  climate 
to  the  exclusion  of  artificial  ventilation  in  school  buildings,  except 
in  special  cases  where  outdoor  or  similar  treatment  is  desirable, 
hospitals,  churches,  factories  and  other  crowded  apartments.  How- 
ever, a  system  of  artificial  ventilation  which  is  deranged  by  the 
opening  of  windows  or  doors  is  hardly  worthy  the  name.  On  the 
other  hand  the  reckless  opening  of  windows  does  not  constitute 
ventilation. 

A  popular  impression  seems  to  exist  that  warm  air  is  not 
fresh  air.  If  a  distinction  be  made  between  warm  air  and  hot  or 
superheated  air  there  is  no  ground  for  such  an  impression.  Prop- 
erly admitted,  filtered  and  warmed,  the  air  supplied  by  a  venti- 
lating system  lacks  in  nothing  but  quantity.  The  air  must  not  be 
so  highly  heated  as  to  rob  it  of  its  freshness,  nor  must  it  be  laden 
with  traces  of  ammonia,  carbon  monoxide  or  other  objectionable 
gases  which  may  be  produced  by  decomposition  of  organic  dust  in 
contact  with  surfaces  at  unnecessarily  high  temperatures. 

In  large  buildings  it  is  often  advisable  to  distinguish  between 
"heating"  and  "ventilating,"  accomplishing  the  first  by  means  of 
direct  radiators  and  the  second  by  a  suitable  indirect  system.  The 
designing  engineer  is,  however,  confronted  with  the  fact  that  too 
often  the  ventilating  system  will  not  be  used  if  the  direct  radiators 

(457) 


214  The  Annals  of  the  American  Academy 

will  heat  the  building, — more  shame  to  the  owner  whose  pocket- 
book  causes  him  to  forget  the  health  and  vigor  of  which  the  ven- 
tilating plant  is  the  conveyor. 

Ventilation,  like  all  things  good,  costs  money,  indeed  it  costs 
more  than  the  heating  of  the  building  without  ventilation,  but  in 
schools,  hospitals,  offices,  and  in  all  such  places  it  is  the  best  pos- 
sible investment  and  the  one  which  will  bring  the  greatest  returns 
in  increased  work  done  and  in  improved  efficiency  generally. 

Results  Accomplished  by  Ventilation 

Professor  Irving  Fisher,  of  Yale  University,  in  addressing 
the  Association  of  Life  Insurance  Presidents,  stated  that,  'It  has 
been  conservatively  calculated  that  eight  years  could  be  added  to 
the  normal  period  of  human  life  by  merely  securing  reasonably 
pure  air,  water  and  milk."  The  statement  is  also  made  that  one 
insurance  company  pays  $800,000  annually  for  death  claims  on  ac- 
count of  tuberculosis  alone,  which  is  known  to  be  preventable,  prin- 
cipally by  the  use  of  plenty  of  fresh  air. 

The  reports  of  the  Boston  City  Hospital  show  that  improved 
general  sanitary  conditions  in  that  institution  changed  the  death 
rate  from  forty-four  per  cent  to  thirteen  per  cent.  In  the  general 
wards  of  the  same  hospital  the  sanitary  improvements  eflfected 
changed  the  death  rate  from  twenty-three  to  six  per  cent,  or  nearly 
in  the  same  ratio  as  in  the  surgical  wards. 

At  the  S.  R.  Smith  Infirmary,  at  Staten  Island,  a  comparison 
was  made  in  two  wards  of  the  same  nature,  containing  the  same 
class  of  patients,  in  which  case  it  was  found  that  in  the  ward  with- 
out ventilation  an  average  of  sixteen  days  was  required  to  effect 
a  cure  while  in  the  ventilated  wards  the  average  was  ten  days. 
This  also  means  a  greater  work  with  the  same  equipment. 

Examples  are  available  showing  the  improvements  in  results 
and  health  due  to  ventilation,  but  the  time  element  is  so  important 
in  such  investigations  that  tests  are  rare  and  difficult  to  make. 

Dr.  J.  N.  Hurty,  Secretary  of  the  State  Board  of  Health, 
Indiana,  is  authority  for  the  statement  that,  "In  properly  heated, 
ventilated  and  lighted  schoolrooms  in  Richmond,  Evansville,  and 
other  cities  in  Indiana,  we  have  secured  an  efficiency  in  the  pupils  of 
twenty-five  per  cent  over  what  it  was  under  old  conditions.  How 
much  of  this   increased  efficiency  is  due  to  better  ventilation  we 

(458) 


Ventilation  and  Public  Health  215 

cannot  say,  but  the  entire  increase  must  be  credited  to  ventilation, 
proper  lighting  and  even  distribution  of  heat,  and  regular  tempera- 
ture. We  have  found  through  a  system  of  marking  and  grading 
pupils  that  those  who  work  under  the  best  sanitary  conditions  will 
accomplish  in  three  years  what  they  ordinarily  accomplish  in  four." 

The  Germania  Insurance  Company  of  New  York,  in  1910,  had 
eighty  clerks  in  one  office.  Previous  to  the  proper  ventilation 
thereof,  ten  per  cent  were  absent  on  account  of  illness  all  the  while. 
Since  then,  absenteeism  has  been  reduced  practically  to  nothing. 

The  vice-president  of  the  Manhattan  Trust  Company  of  New 
York  states  that  by  proper  ventilation  he  has  so  increased  the  effi- 
ciency of  his  clerical  force  that  he  has  been  able  to  reduce  the 
number  of  employees  four  per  cent. 

The  records  of  the  United  States  Pension  Bureau  show  that 
when  the  offices  of  the  department  were  located  in  scattered  and 
poorly  ventilated  buildings,  18,736  days  were  lost  by  employees 
through  illness  in  one  year  and  about  the  same  number  for  several 
successive  years.  When  the  department  became  established  in 
new  well-ventilated  quarters,  the  loss  was  reduced  to  10,114  days' 
absence  on  account  of  illness,  although  the  working  force  was  much 
larger. 

In  the  printing  establishment  of  Mr.  C.  J.  O'Brien,  in  New 
York,  a  ventilation  system  was  installed  because  of  the  insistence 
of  the  State  Department  of  Labor  that  the  law  be  complied  with, 
the  order  having  been  resisted  for  two  years.  After  the  system  had 
been  in  use  a  year  the  proprietor  stated  that  had  he  known  in 
advance  of  the  results  to  be  obtained  no  order  would  have  been 
necessary  to  have  brought  about  the  installation.  Whereas  for- 
merly the  men  hiad  left  work  on  busy  days  in  an  exhausted  condition 
and  sickness  was  common,  now  the  men  left  work  on  all  days  in 
an  entirely  different  condition,  and  sickness  had  been  very  much 
reduced.  The  errors  in  typesetting  and  time  required  for  making 
corrections  were  greatly  reduced. 

Townsend,  Grace  &  Co.,  of  Baltimore,  built  a  straw  hat  factory 
without  ventilating  apparatus.  The  first  two  winters  after  occu- 
pation the  sick  rate  was  twenty-seven  and  one-half  per  cent.  A 
ventilating  system  was  then  installed,  after  which  the  winter  sick 
rate  fell  to  seven  per  cent.  It  was  claimed  that  the  ventilating 
system  paid  for  itself  in  one  year. 

(450) 


2i6  The  Annals  of  the  American  Academy 

In  Strouse  Brothers'  clothing  factory,  of  Baltimore,  the  sick 
rate  was  reduced  about  one-half  by  the  installation  of  an  inferior 
ventilating  system. 

The  army  medical  officers  gave  some  of  the  earliest  definite 
data  on  air  quantities  required  in  ventilation  work  and  have  fur- 
nished many  illustrations  of  the  value  of  ventilation,  as  has  also 
the  naval  service.  Munson  records:  "The  medical  officer  at  Fort 
Douglass,  in  1898,  reported  an  immediate  decrease  in  the  number 
of  cases  of  tonsilitis  among  the  troops  at  that  post  on  installing 
suitable  arrangements  in  the  previously  improperly  ventilated 
barracks." 

Legislation  as  to  Ventilation 

Much  has  been  written  on  the  value  of  ventilation,  but  little 
has  been  accomplished  toward  bringing  adequate  relief  from  present 
oppressive  conditions  to  those  who  are  least  able  to  demand  it, 
the  children  in  the  schools,  the  workers  in  the  factories,  and  the 
dwellers  in  the  congested  districts. 

But  seven  states  (Massachusetts,  New  York,  New  Jersey, 
Pennsylvania,  Virginia,  Utah  and  Minnesota)  have  school  venti- 
lation laws,  and  but  three  (Connecticut,  Vermont  and  Indiana)  have 
state  board  of  health  rulings  requiring  ventilation  of  school  build- 
ings, but  not  one  of  them  refers  to  the  subjects  of  dust,  humidity, 
or  source  of  air  supply.  These  laws,  however,  are  a  big  step  in 
advance,  and  every  state  should  have  a  law  at  least  as  good. 
Compulsory  ventilation  laws  are  under  consideration  in  Illinois, 
Indiana  and  Wisconsin.  Twenty-one  states  have  laws  governing 
factory  ventilation,  the  most  of  the  laws  referring  to  removal  of 
special  dust,  fumes,  etc.,  rather  than  to  air  supply,  its  quality  or  quan- 
tity, and  but  one  law  covers  conditions  in  mercantile  establishments. 
But  very  few  of  these  laws  are  of  real  merit.  A  few  cities  have  local 
ordinances  of  doubtful  value.  Such  laws  should  be  made  to  include 
all  classes  of  buildings  that  are  densely  occupied,  such  as  court 
houses,  hospitals,  asylums,  reformatories,  houses  of  refuge,  prisons, 
schools,  colleges,  theatres,  auditoriums,  factories,  stores  and  all 
places  where  people  congregate.  They  should  state  the  minimum 
air  supply  (quality  and  quantity)  and  removal,  prescribe  the 
official  who  has  authority  to  administer  the  law,  and  they  should 

(460) 


Ventilation  and  Public  Health  217 

include  provisions  for  the  removal  of  all  dusts  in  a  sanitary  manner. 
Humidity  and  temperature  should  be  prescribed  where  possible. 

But  a  very  feeble  beginning  of  a  most  important  movement 
has  thus  far  been  made.  It  may  properly  be  considered  a.  form  of 
the  ever-growing  police  power  of  the  people,  to  be  exercised  for 
the  welfare  of  the  defenseless.  It  should  be  encouraged  and  par- 
ticipated in  by  all  those  interested  in  the  welfare  of  humanity,  and 
especially  those  bodies  having  to  do  with  the  public  health,  the 
welfare  of  the  workers  and  the  interests  of  the  children.  Every 
parent  has  the  right  to  demand  that  the  school,  in  which  the  child 
spends  approximately  one-fifth  of  its  time  for  a  large  portion  of  the 
year,  be  thoroughly  ventilated  and  in  sanitary  condition.  No  hos- 
pital should  be  considered  worthy  of  use  or  patronage  in  which  an 
effort  at  thorough  and  systematic  ventilation,  both  natural  and 
artificial,  is  not  fundamentally  a  part  of  the  equipment  and  service. 
Constant  agitation  is  essential  in  this  as  in  other  worthy  reforms. 
The  prevailing  ignorance  of  the  worth  of  ventilation  and  the 
indifference  of  the  public  are  the  greatest  handicaps  in  the  onward 
progress  of  ventilation.  The  physician,  to  the  success  of  whose 
work  ventilation  will  so  largely  contribute,  should  realize  the  value 
of  ventilation.  Some  doctors,  and  among  them  some  hospital  ex- 
perts, fail  to  recognize  the  limitations  of  natural  ventilation  and  the 
need  of  supplementing  it  with  an  efficient  artificial  ventilation 
system. 

The  Architect  Should  be  Aided  by  the  Sanitary  Engineer 

It  is  unfortunate  for  the  progress  of  ventilation  that  much 
skepticism  has  been  aroused  as  to  the  efficacy  of  artificial  ventilating 
systems  because  of  faulty  installations  made  in  the  past.  The  too 
prevalent  impression  that  ventilation  is  not  an  exact  science  is  largely 
due  to  the  fact  that  owners  will  too  often  accept  as  an  expert  any 
plumber  or  steamfitter  who  can  put  out  his  shingle  and  who  claims 
to  be  a  heating  and  ventilating  engineer.  Ventilating  work  should 
be  designed  by  experienced  engineers  who  are  independent  of  any 
interest  in  contracting  work  or  materials,  and  should  be  installed 
by  contractors  of  equal  merit  in  their  line,  under  the  supervision 
of  the  designer. 

Improper  operation  of  systems  when  installed  has  injured  the 
cause   of   ventilation.     The   responsibilities   of   operating  a   venti- 

(j6t) 


2i8  The  Annals  of  the  American  Academy 

lating  plant  costing  thousands  of  dollars,  the  economical  or  efficient 
use  of  hundreds  of  tons  of  coal,  and  above  all  the  keeping  of  the 
health  of  hundreds  of  school  children,  or  of  an  equal  number  of 
sick  or  well  adults,  and  the  custody  of  their  working  efficiency, 
demand  higher  qualifications  than  those  necessary  for  the  shoveling 
of  coal  and  ashes  or  the  wielding  of  the  deadly  feather  duster. 

The  architect  for  a  new  building  should  be  provided  by  the 
owner  with  the  assistance  of  expert  engineering  services  covering 
the  heating,  ventilating  and  similar  equipment.  For  this  is  it  just 
and  proper  that  the  architect  be  paid  extra  by  the  owner  and  that 
he  should  not  be  left  dependent  upon  the  help  of  contractors  or 
manufacturers  of  materials  whose  interests  are  naturally  not  those 
of  the  owner?  Too  many  people  expect  the  architect  to  be  artist, 
designer,  constructionist,  lan^Jscape  gardener,  civil,  mechanical, 
electrical  and  sanitary  engineer,  chemist,  lawyer,  jury  and  judge. 
The  erection  of  a  modern  public  building  involves  an  architectural 
problem  dealing  with  design  and  construction,  and  it  also  involves 
engineering  problems  requiring  familiarity  with  the  entirely  dif- 
ferent problems  presented  by  air,  water  and  steam  in  their  dif-. 
ferent  conditions  and  relations  to  each  other.  In  brief,  one  problem 
is  architectural  and  another  engineering  in  its  nature,  the  two  in- 
volving different  training  and  experience. 

What  this  paper  has  attempted  to  show  may  be  summarized  as 
follows : 

1.  That  all  the  fresh  air  possible  should  be  given  free  access  to  the  lungs 
by  out-of-door  living,  and  by  natural  ventilation  of  our  habitations,  breezes 
being  less  to  be  feared  than  vitiated  air. 

2.  That  artificial  ventilation  is  absolutely  essential  as  an  aid  to  natural 
ventilation,  that  indoors  may  be  kept  in  the  best  condition  possible,  i.  e.,  as 
near  as  possible  like  out-of-doors. 

3.  That  warm  air  (as  distinguished  herein  from  hot  or  superheated  air) 
is  equally  as  beneficial  as  cold  air,  lacking  only  in  quantity,  the  matter  of 
expense  prescribing  this  limitation. 

4.  That  the  ventilating  system  which  fails  to  take  cognizance  of  the 
subjects  of  dust,  humidity  and  temperatiye  are  foredoomed  to  failure,  quality 
of  air  being  quite  as  essential  as  quantity! 

5.  That  efficient  ventilating  systems,  fulfilling  all  of  the  above  require- 
ments, are  available  for  all  classes  of  buildings.  The  installation  of  such 
systems  assumes  the  employment  of  experienced,  independent  engineers  as 
distinguished  from  those  connected  with  contracting  or  manufacturing  firms. 

(462) 


Ventilation  and  Public  Health  219 

Efficient  ventilation  also  involves  the  employment  of  capable  operating  en- 
gineers, resulting  in  efficiency  and  economy. 

6.  That  dullness,  restfulness,  forgetfulness  and  general  deficiency,  being 
incident  to  a  weakened  vitality,  are  the  results  of  the  ill-ventilated  school- 
room, while  a  quicker  perception,  improved  memory,  increased  accomplish- 
ment, vigor,  health  and  happiness  go  arm  in  arm  with  ample  school-room 
ventilation. 

7.  That  a  lengthened  illness  and  a  lessened  proportion  of  cures  are 
chargeable  to  the  insufficiently  ventilated  hospital,  while  the  fresh  air  sup- 
plied by  an  efficieiit  ventilating  system  is  the  angel  of  health  bringing  relief 
and  healing  to  the  weakened  vitality. 

8.  That  a  poorer  and  a  smaller  output  and  more  sick  employees  are  the 
result  of  a  foul-aired  factory  or  mercantile  establishment,  while  ventilation 
means  less  mistakes  to  be  corrected,  less  idle  machinery,  and  the  maximum 
efficiency  of  plant  and  employees. 

9.  That  the  general  ventilation  of  homes  would  mean  less  colds, 
catarrh  and  other  preventable  ills ;  and  of  auditoriums  and  places  of  enter- 
tainment would  mean  greater  enjoyment  on  the  part  of  the  audience  and  an 
appreciable  reduction  in  headaches  and  enervation. 

10.  That  the  health  of  the  individual  largely  determines  the  health  oC 
the  public.  The  greater  necessity  for  special  ventilation  where  many  people 
are  assembled  is  due  to  heat  and  moisture  given  off  and  to  the  increased 
oxygen  required. 


(463) 


PART  THREE 


Elimination  of  Disease — Physical 
Care  of  Individuals 


(465) 


SOCIAL  SERVICE  WORK  IN  HOSPITALS 


By  Richard  C.  Cabot,  M.D., 
Boston,  Mass. 


The  promotion  of  public  health  is  only  part,  though  perhaps 
the  largest  part,  of  the  usefulness  aimed  at  by  those  who  have  been 
active  in  establishing  social  workers  side  by  side  with  physicians 
in  hospital  work.  The  social  worker  is  needed  in  the  hospital  to 
make  the  place  less  grim,  to  keep  the  standard  of  good  manners 
and  decency  higher  than  it  otherwise  tends  to  be,  to  bring  to  bear 
upon  hospital  routine  and  hospital  management  the  criticism  of 
a  friendly,  yet  keen-sighted,  observer,  and  to  focus  upon  each  indi- 
vidual patient  all  the  forces  of  helplessness  existing  in  the  charities^ 
the  churches,  the  labor  unions,  lodges  and  other  voluntary  asso- 
ciations, as  well  as  the  opportunities  for  recreation  and  education 
of  which  the  patient  may  be  especially  in  need. 

All  these  types  of  usefulness  are  distinguishable  from  that 
which  makes  the  social  worker  in  hospitals  part  of  the  public  health 
movement.  For  I  take  it  that  all  activities  on  behalf  of  public 
health  are  characterized  by  their  special  interest  in  prevention,  and 
in  the  care  and  preservation  of  health  in  large  masses  of  people 
rather  than  in  the  individual  sufferer,  after  sickness  has  invaded 
him.  I  shall  leave  out  of  account,  therefore,  a  large  part  of  what 
seem  to  me  the  most  beneficent  and  important  activities  of  the 
hospital  social  worker.  His  efforts  to  civilize  and  colonize  those 
dreary  and  uncultivated  wastes  ordinarily  known  as  hospitals  cannot 
be  dealt  with  in  this  article. 

Some  hint  of  the  preventive  work  done  by  hospital  social 
workers  may  be  obtained  from  the  following  story :  A  young  infant 
entered  the  wards  of  the  Massachusetts  General  Hospital  early  one 
summer,  a  few  years  ago,  for  a  stomach  and  bowel  trouble,  of  the 
ordinary  fermentative  or  "food"  type.  The  baby  was  treated  in 
the  wards  for  about  three  weeks  and  perhaps  thirty  dollars'  worth 
of  care  was  expended  upon  it.  At  the  end  of  that  time  it  seemed 
entirely  well  and  was  delivered  over  to  the  mother,  according  to 

(467) 


224  ^^^  Annals  of  the  American  Academy 

the  hospital  custom,  without  any  special  instruction  as  to  the  future. 
The  mother,  therefore,  continued,  in  the  same  generous  and  whole- 
hearted manner  which  had  characterized  her  previous  actions,  to 
give  the  baby  a  little  of  everything  that  was  going.  Not  many 
weeks  passed  before  the  baby's  digestive  tract  was  as  thoroughly 
upset  as  it  had  been  the  first  time  and  as  anyone  could  have  pre- 
dicted would  be  the  case  again,  if  the  hospital  neglected  its  duties 
toward  preventive  medicine. 

In  this  case  the  social  worker  undertook  the  instruction  of  the 
mother  regarding  the  elementary  principles  of  infant  feeding,  found 
her  very  amenable  to  the  teaching  and  succeeded  in  this  way  in 
preventing  another  relapse. 

The  waste  of  money  as  well  as  of  human  energy  and  suffering 
entailed  by  the  failure  on  the  part  of  most  hospitals  to  take  note 
of  the  public  and  preventive  aspects  of  their  work,  is  well  illus- 
trated by  the  case  just  described.  Warning  and  instruction  as  to 
the  future  is  most  effective  when  a  person  has  just  experienced 
in  the  form  of  disease  the  consequences  which  make  the  need  of 
such  instruction  come  home  to  him.  Every  case  of  disease  is  thus 
an  opportunity  for  the  prevention  of  further  disease  through  the  op- 
portunities which  it  affords  for  instruction  to  the  sufferer  and  to  his 
family  and  friends.  We  have  recognized  this  fact  in  relation  to 
the  object  lessons  presented  by  the  out-door  treatment  of  tubercu- 
losis, and  of  the  diseases  of  infancy.  AH  over  the  country  we  have 
visiting  nurses  doing  preventive  work  against  tuberculosis  and 
infant  mortality  in  connection  with  hospital  clinics.  But  we  have 
not  sufficiently  realized  as  yet  that  in  the  functional  and  nervous 
diseases,  in  many  affections  of  the  joints,  the  gastro-intestinal  tract 
and  the  circulation,  almost  every  case  which  presents  itself  at 
a  clinic,  should  be  a  finger-post  pointing  to  the  need  of  preventive 
work  in  the  home.  Such  cases  issue,  in  most  instances,  out  of  a 
hot-bed  of  home  conditions  which  are  bound  to  sprout  more  of  the 
same. 

At  the  present  juncture  when  these  opportunities  for  preventive 
work  are  recognized  and  met  through  district  nurses  only  in  the 
field  of  tuberculosis  and  infant  mortality,  the  social  worker  has 
to  pick  up  what  is  left  and  do  the  work  of  hygienic  instruction  for 
all  the  rest  of  the  preventable  diseases.  Such  teaching  may  be  given 
at  the  clinic,  but  is  usually  more  effective  in  the  home  where  the 

(468) 


Social  Service  Work  in  Hospitals  225 

worker  can  see  and  attempt  to  overcome  the  special  obstacles  pre- 
sented by  housing  conditions,  industrial  derangements  and  domestic 
friction. 

Another  type  of  preventive  work  which  the  hospital  social 
worker  finds  ready  to  her  hand,  concerns  the  problems  of  industrial 
hygiene.  Every  case  of  lead  poisoning,  for  example,  should  be  the 
occasion  and  the  incentive  for  investigation  of  the  conditions  of 
work  which  are  responsible,  wholly  or  in  part,  for  the  disease.  The 
social  worker  is  not  content  with  following  up  the  radiating  sug- 
gestions of  possible  disease  in  other  members  of  the  family  of  each 
patient.  The  other  members  of  the  trade,  perhaps  similarly  exposed 
to  disease,  loom  up  before  her  vision.  Are  the  conditions  of  ven- 
tilation, of  posture,  of  temperature,  such  as  they  should  be  in  the 
shop  where  this  patient  works,  or  are  they  such  as  to  be  preparing, 
beyond  reasonable  doubt,  a  fresh  supply  of  cases  similar  to  that 
which  presents  itself  at  the  clinic?  Are  the  hours  of  work  such 
as  must  inevitably  maim  a  certain  percentage  of  all  who  undertake 
it?  If  so,  it  is  the  business  of  the  social  worker  to  advertise  these 
facts  and  to  do  what  she  can  to  change  them. 

Besides  the  preventive  work  accomplished  by  the  education 
of  the  patient,  so  that  he  shall  not  fall  into  similar  misfortune  in 
future,  besides  the  warnings  given  to  his  family  and,  through  them, 
to  his  neighborhood,  I  have  sketched  in  the  previous  paragraph 
the  preventive  work  of  the  hospital  social  worker  in  the  field  of 
industrial  hygiene.  A  third  opportunity  for  preventive  work  is 
the  education  of  the  hospital  physicians.  We  ordinarily  say  very 
little  about  this  part  of  the  work  which,  nevertheless,  is  one  of  the 
most  important  branches.  Physicians  are,  just  now,  undergoing 
a  process  of  conversion  or  regeneration  whereby  the  interest  of 
the  general  public  is  becoming  paramount  in  their  work.  There 
is  no  more  fruitful  field  for  such  conversion  than  the  well-equipped 
hospital  clinic  with  the  social  worker  as  part  of  the  equipment. 
Physicians  learn  all  the  more  swiftly  for  not  being  conscious  of  the 
process.  They  come  in  time  to  look  on  each  patient,  not  only  as 
an  opportunity  for  diagnosis  and  treatment,  not  only  as  a  subject 
for  medical  instruction,  but  still  more  as  a  symptom  of  some  dis- 
ease in  the  community  which,  from  the  social  point  of  view,  is  far 
more  important  than  the  individual  sufferer.  Each  physician,  so 
educated,  finds  his  world  transformed,  and  can  never  be  content 

(469) 


226  The  Annals  of  the  American  Academy 

again  with  the  unmitigated  medical  regime.  He  becomes  a  live  wire 
for  preventive  medicine. 

Hospital  administrators,  trustees  and  managers  are  also  sub- 
ject to  inoculation,  though  usually  more  resistant,  because  their 
contact  with  the  social  worker  is  less  direct  and  less  frequent.  Nev- 
ertheless their  influence  for  preventive  medicine,  when  once  they 
become  aroused  to  the  fact  that  the  hospital  is  primarily  a  public 
servant,  like  the  public  school,  is  wider  and  deeper  than  that  of  the 
staff  physician. 

Still  another  group  of  persons,  who  are  rapidly  becoming  trans- 
formed into  missionaries  for  public  health,  owing  to  their  contact 
with  hospital  social  workers,  is  the  great  body  of  the  social  workers 
at  large.  Indeed  they  are  becoming  almost  too  medical — too  exclu- 
sively hygienic  in  their  outlook.  The  programs  of  modern  charity 
conferences  are  apt  to  be  overshadowed  by  topics  like  tuberculosis, 
infant  mortality,  venereal  disease,  alcoholism,  industrial  accidents 
and  insanity.  Preventive  philanthropy  has  come  to  be  practically 
identical  with  preventive  medicine,  and  while  one  may  regret  this 
from  the  point  of  view  of  philanthropy  itself,  it  is  an  enormous 
gain  to  preventive  medicine.  Indeed  it  may  be  said  that  the  social 
workers  have  initiated  most,  if  not  all,  of  the  great  campaigns 
against  disease  that  have  been  taken  up  in  this  country  during  the 
past  decade. 

It  must  be  evident  from  what  has  been  said  that  the  work  of 
the  district  nurse  is  scarcely  to  be  distinguished  from  that  portion 
of  the  hospital  social  worker's  activities  concerned  with  preventive 
medicine.  All  the  so-called  tuberculosis  nurses,  all  the  school-nurses, 
all  of  those  engaged  in  the  work  for  young  infants,  are  busy  upon 
the  same  tasks  which  occupy  the  hospital  social  worker,  since  they 
are  supposed  to  instruct  as  well  as  to  nurse  their  families,  and  to 
extend  their  teaching  as  widely  as  they  can  into  the  family  and  the 
neighborhood. 

Considerable  confusion  and  some  bitterness  arises  not  infre- 
quently out  of  the  fact  just  mentioned — that  the  social  worker  is 
often  asked  to  do  nurses'  work.  For  the  technical  duties  of  the 
nurse  the  social  worker  is,  of  course,  unfitted.  aAd  no  one  is  more 
vividly  aware  of  this  fact  than  the  nurse,  who  is  apt,  therefore, 
to  regard  the  social  worker  as  an  unqualified  intruder.  On  the 
other  hand,  the  social  worker  herself  is  apt  to  become  narrow  and 

(470) 


Social  Service  Work  in  Hospitals  227 

distracted  from  her  proper  path,  owing  to  the  multitude  of  purely 
medical  tasks  which  she  is  called  upon  to  perform.  Nevertheless 
there  arises  out  of  this  very  confusion  a  broadening  of  the  ideas 
and  methods  of  the  nurse  who  absorbs,  more  or  less  unconsciously, 
a  good  deal  of  the  social  knowledge  which  comes  to  her  directly 
from  the  social  worker  and  indirectly  through  the  socially  converted 
doctor.  Doubtless  there  will  issue  out  of  this  confusion  a  new 
synthesis  of  duties,  a  new  recognition  of  the  fact  that  medical 
needs  form  the  best  of  all  points  of  entrance  for  anyone  who  would 
be  a  missionary  or  a  servant  of  the  whole  life  of  humanity. 


(471) 


MOUTH   HYGIENE   AND   ITS   RELATION   TO   HEALTH 


By  Arthur  H.  Merritt,  D.D.S., 
New  York  City. 


There  is  not  any  one  single  thing  more  important  to  the  public  in  the 
whole  range  of  hygiene  than  the  hygiene  of  the  mouth.  If  I  were  asked  to 
say  whether  more  physical  deterioration  was  produced  by  alcohol  or  by 
defective  teeth,  I  should  unhesitatingly  say  defective  teeth. — William  Osier, 
M.  D. 

There  is  probably  no  people  who,  as-  a  whole,  give  as  much 
attention  to  mouth  hygiene  as  do  Americans,  and  though  their  sus- 
ceptibility to  dental  diseases  is  high,  it  is  not  higher  than  that  of 
other  nations  who  exercise  little  or  no  care.  One  explanation  of 
this  high  susceptibility  will  be  found  in  the  enormous  amount  of 
sugar  which  we  consume  as  a  nation,  reported  in  1906  as  being 
6,450,653,967  pounds,  or  about  92)^  pounds  per  capita,  fifteen  pounds 
higher  than  that  of  Great  Britain,  our  closest  competitor.  And  yet, 
with  all  our  boasted  pre-eminence,  we  are  as  a  nation  lamentably 
ignorant  of  the  first  principles  of  what  constitutes  mouth  hygiene. 

Nor  are  we  one  whit  less  ignorant  regarding  the  pernicious 
eflfect  of  mouth  infection  upon  our  national  health.  It  has  been  said 
that  nowhere  in  the  human  body  will  so  much  filth  be  tolerated  as 
in  the  mouth,  the  avenue  through  which  must  pass  all  food,  upon 
which  depends  the  nourishment  of  the  body  and  the  maintenance  of 
health. 

The  number  of  people  in  the  United  States,  who  patronize  the 
dentist,  except  for  the  occasional  extraction  of  a  tooth,  has  been 
variously  estimated  at  from  four  to  ten  per  cent.  If  these  figures  be 
true,  it  means  that  there  are  not  less  than  seventy-five  million  people 
in  this  country  who  give  little  or  no  attention  to  mouth  hygiene. 

Under  the  most  favorable  conditions  the  mouth  may  be  re- 
garded as  being  an  almost  ideal  culture  medium  for  germ  life.  In 
fact,  it  presents  in  point  of  temperature,  mtiisture,  nutritive  material^ 
etc.,  an  almost  perfect  breeding-place.  Upward  of  twenty  varieties, 
many  of  them  pathogenic  (disease-producing)  in  their  nature,  have 
been  found  to  be  normal  residents  of  the  mouth  under  certain  con- 
ditions.    Among  these  may    be    mentioned    the  streptococcus  and 

(472) 


Mouth  Hygiene  and  its  Relation  to  Health  229 

staphylococcus,  both  pus  producers,  and  always  present  in  the 
mouth  in  greater  or  less  numbers,  the  pneumococcus,  the  causative 
agent  in  pneumonia,  and  also  a  frequent  resident  of  the  mouth,  the 
dreaded  tubercle  bacillus  and  Vincent's  fusiform  bacillus,  only  to 
mention  a  few  of  the  more  virulent  types.  One  investigator  who  has 
given  years  to  the  study  of  mouth  bacteria  has  estimated  the  num- 
ber of  germs  in  one  unclean  mouth  at  1,140,000,000. 

Many  of  the  diseases  of  the  mouth  are  directly  or  indirectly 
caused  through  the  agency  of  these  germs.  Fortunately,  for  hu- 
manity, nature  has  provided  the  mouth  with  soft  tissues  that  are 
unusually  resistant  to  infection.  Every  one  knows  that  a  wound  in 
the  mouth,  such  for  example  as  that  caused  by  the  extraction  of  a 
tooth,  rarely  becomes  infected,  notwithstanding  the  fact  that  it  may 
be  consantly  bathed  with  organisms  that  under  other  circumstances 
might  cause  serious  infection.  It  is  true  that  fatalities  from  such 
causes  are  not  unknown  when  for  some  reason  the  resistance  to 
infection  is  low,  but  they  are  comparatively  rare. 

While  the  local  penalties  attached  to  an  unsanitary  mouth  are 
sufficiently  grave  to  warrant  serious  consideration,  they  are  as  noth- 
ing to  those  which  they  inflict  upon  the  general  health.  We  have 
too  long  considered  the  mouth  as  an  independent  entity,  forgetting 
that  here  it  is  that  the  first  steps  in  digestion  are  taken — the  only 
steps,  in  fact,  over  which  we  have  the  slightest  control.  Not  only  is 
it  important  that  food  be  thoroughly  masticated,  which  is  impos- 
sible without  sound  and  healthy  teeth,  but  it  is  equally  important  that 
the  mouth  in  which  mastication  takes  place  be  a  clean  mouth. 

Factors  in  an  Unclean  Mouth.  Among  the  factors  which  make 
for  an  unclean  mouth  may  be  mentioned  caries  of  the  teeth,  pyorrhea 
alveolaris  or  so-called  "Riggs  Disease,"  chronic  abscesses,  commonly 
called  ulcerated  teeth,  or  gum  boils,  irregular  or  mal-posed  teeth, 
partially  erupted  "wisdom  teeth,"  deposits  of  salivary  tartar,  inflamed 
and  bleeding  gums,  the  habitual  use  of  tobacco,  ill-fitting  artificial 
teeth,  such  as  crowns,  bridges,  plates,  etc. 

Decay  of  the  Teeth.  Of  all  these,  the  most  common,  and  prob- 
ably the  most  pernicious  in  its  effect  upon  the  hygiene  of  the  mouth, 
is  caries  of  the  teeth.  So  nearly  universal  an  affection  is  this  that 
it  has  been  characterized  "The  Peoples'  Disease."  Few  individuals 
or  nations  escape  its  ravages.  So  far  as  is  at  present  known,  the 
Esquimaux,  certain  tribes  of  American  Indians,  the  Icelanders,  the 

(473) 


230  The  Annals  of  the  American  Academy 

Lapps,  the  Igorots  (all  more  or  less  completely  outside  the  influence 
of  civilization)  are  the  only  people  who  are  more  or  less  exempt 
from  dental  caries. 

Like  many  another  disease,  it  is  brought  about  through  the 
agency  of  micro-organisms,  and  in  this  instance  micro-organisms 
resident  within  the  mouth.  These  germs  possess  the  property  un- 
der favorable  circumstances  of  converting  carbohydrates  (starchy 
foods,  sugars,  etc.)  into  acids,  which  in  turn  dissolve  out  the  lime 
salts  of  the  enamel,  and  this  notwithstanding  the  fact  that  the  enamel 
is  the  hardest  tissue  within  the  body,  not  less  than  97  per  cent,  of  it 
being  inorganic. 

The  rapidity  with  which  this  phenomenon  is  accomplished  will 
depend  upon  the  number  of  organisms  present,  the  cleanliness  or 
uncleanliness  of  the  mouth,  and  the  resistance  which  the  teeth,  or 
the  body  as  a  whole,  offers  to  their  activity.  Once  the  solution  of 
the  enamel  has  taken  place,  and  the  dentine,  containing  28  per  cent, 
of  organic  material,  is  exposed  to  the  combined  influence  of  germs 
and  acid,  the  progress  of  the  disease  becomes  more  rapid,  it  being 
then  only  a  question  of  time,  unless  interfered  with,  when  the  pulp 
of  the  tooth  becomes  involved,  followed  by  pain,  death  of  the  pulp 
and  eventual  loss  of  the  tooth.  Thus  it  will  be  seen  that  the 
progress  of  the  disease  is  comparatively  slow,  that  decay  which  has 
progressed  to  the  point  of  pain  is  not  a  matter  of  days  or  weeks,  but 
rather  of  months  or  years.  An  aching  tooth  does  not  spring  into 
being  in  a  day,  and  means  nothing  less  than  negligence  long  con- 
tinued. While  caries  of  the  teeth  is  not  limited  to  any  age,  and  may 
afflict  any  one  between  infancy  and  old  age,  it  is,  nevertheless,  essen- 
tially a  disease  of  childhood,  its  most  active  period  being  between  the 
ages  of  six  and  twenty.  If  its  ravages  could  be  prevented  during 
this  active  period,  the  dental  ills  of  adult  life  would,  with  proper 
care,  be  very  materially  reduced.  The  menace  in  bad  teeth  cannot 
but  be  apparent  to  any  one  who  has  given  the  subject  any  consid- 
eration whatever,  and  especially  is  it  pernicious  in  its  influence  upon 
the  health  and  efficiency  of  the  growing  child.  Decaying  teeth  ren- 
der thorough  mastication  impossible,  and  establishes  early  in  life 
the  habit  of  bolting  the  food — a  habit  which  may  continue  throughout 
life.  Aloreover,  the  filth  which  is  inseparable  from  decaying  teeth 
and  neglected  mouth  hygiene  is  mixed  with  the  food,  and  carried 
into  the  stomach  as  a  further  tax  upon  the  digestive  apparatus.     In 

(474) 


Mouth  Hygiene  and  its  Relation  to  Health  231 

a  word,  decaying  teeth,  especially  in  the  mouth  of  a  child,  spells 
poor  nutrition,  and  poor  nutrition  means  poor  health  and  a  low 
order  of  efficiency. 

Pyorrhea  Aveolaris  (Riggs  Disease).  If  decaying  teeth  is 
essentially  a  disease  of  childhood,  pyorrhea  aveolaris  may  be  said 
to  be  essentially  a  disease  of  adult  life.  Among  adults,  in  some 
form,  it  is  very  common,  and  is  responsible  for  the  loss  of  many 
otherwise  healthy  teeth,  and  the  indirect  cause  of  not  a  few  ills 
more  or  less  seriously  aflfecting  general  health.  The  disease  attacks 
the  tissues  supporting  the  teeth,  involving  the  pericemental  mem- 
brane, bony  socket  and  gums,  and  is  characterized  by  loosening  of 
the  teeth,  inflammation  and  recession  of  the  gums,  necrosis  of  the 
bony  walls  surrounding  the  teeth,  and,  in  most  instances,  a  discharge 
of  pus  at  the  free  margin  of  the  gums.  This  discharge  is  more  or 
less  persistent,  the  amount  depending  upon  the  number  of  teeth 
involved,  the  advanced  stage  of  the  disease  and  the  nature  of  the 
infecting  organisms.  In  its  early  stages  there  is  little  to  attract  the 
attention  of  the  patient.  It  is  only  when  the  disease  becomes  well 
advanced  on  one  or  more  of  the  teeth  that  the  patient's  attention 
is  attracted  to  it.  Then  it  is  that  there  will  be  noticed  a  slight 
loosening  of  the  affected  teeth,  with  possible  elongation,  sensitive- 
ness to  heat  and  cold,  sweets  and  acids  ;  pain  on  mastication  ;  periodic 
and  painful  swelling  of  the  gums,  due  to  infection,  etc.  One  or  all 
of  these  symptoms  may  be  present,  their  severity  depending  largely 
upon  the  stage  of  the  disease.  Pyorrhea  aveolaris,  is,  first,  last  and 
all  the  time,  a  filth  disease,  encouraging  the  growth  of  pyogenic 
(pus-producing)  organisms,  permitting  the  lodgment  of  particles 
of  food  between  the  loosened  teeth,  and  discharging  its  purulent 
matter  into  the  mouth  with  every  act  of  mastication.  A  condition 
such  as  this  means  not  only  an  unclean  and  unhealthy  mouth,  with 
ultimate  loss  of  the  teeth,  but  means  also  eventual  impairment  of 
the  health.  As  a  causative  factor  in  gastro-intestinal  diseases,  per- 
nicious anemia  and  arterio-sclerosis  (hardening  of  the  arteries) — 
only  to  mention  some  of  the  more  obvious  results  of  mouth  infec- 
tion— pyorrhea  aveolaris  has  never  received  the  attention  which  its 
importance  demands.  If  its  presence  in  the  mouth  were  a  matter 
of  weeks  or  months  only,  its  eflFect  upon  general  health  might  be 
ignored,  but  when  it  is  remembered  that  not  infrequently  it  may, 
because  of  its  chronic  nature,  persist  almost  throughout  adult  life, 

(475) 


2;^2  The  Annals  of  the  American  Academy 

and  that  without  more  than  occasional  painful  symptoms,  one  is 
made  to  realize  that  it  is  a  disease  which  merits  serious  consideration.^ 

Chronic  Aveolar  Abscesses.  Perhaps  the  third  most  potent 
factor  in  an  unclean  mouth  is  aveolar  abscesses,  commonly  referred 
to  as  ulcerated  teeth,  or  gum  boils.  These  are  common  to  all  ages, 
from  the  time  the  temporary  teeth  are  erupted  and  as  long  as  any 
teeth  remain.  They  are  always,  with  rare  exceptions,  caused 
through  a  neglect  to  properly  care  for  a  decaying  tooth  in  its  early 
stages.  Decay  having  been  allowed  to  progress  from  its  early 
manifestations  through  various  stages  until  the  pulp,  situated  in  the 
center  of  the  tooth  and  root,  and  containing  arteries,  veins,  nerves 
and  connective  tissue,  becomes  involved  by  the  germs  of  decay ;  death 
of  the  tooth  follows.  Unless  recognized,  and  proper  treatment  insti- 
tuted, gangrene  of  the  pulp  takes  place,  followed  by  a  discharge 
of  the  products  of  decomposition  through  the  end  of  the  root  into 
the  surrounding  tissues. 

Infection  takes  place,  followed  in  most  instances  by  acute  pain, 
elongation  of  the  affected  tooth,  swelling  of  the  face,  and  eventual 
discharge  of  pus,  usually  within  the  mouth.  These  symptoms  last 
two  or  three  days,  and  are  accompanied  by  an  elevation  of  tem- 
perature, loss  of  appetite,  digestive  disturbance,  etc.  With  the  dis- 
charge of  pus,  the  acute  symptoms  subside,  and  all  that  remains  as 
evidence  of  the  abscess  is  the  opening  through  which  the  pus  dis- 
charged itself.  Occasionally  this  occurs  without  pain,  but  in  both  in- 
stances the  results  are  the  same,  viz.,  a  chronic  sinus  or  gumboil, 
which,  as  long  as  the  cause  remains,  will  continue  to  discharge.  As 
the  point  of  discharge  is  usually  within  the  mouth,  this  discharge,  ac- 
companied as  it  is  with  virulent  pus-producing  organisms,  usually  the 
streptococcus,  finds  it  way  into  the  stomach,  to  be  resorbed  into  the 
circulation.  Treatment  consists  in  the  removal  of  the  gangrenous 
tooth  pulp,  disinfection  of  the  roots,  and  filling  of  the  tooth.  Such 
abscesses  are  very  common  among  children  as  a  result  of  the  decay 
of  their  temporary  teeth,  eight  of  which  are  not  succeeded  by  their 
permanent  successors  until  the  twelfth  year.  Right  here  let  it  be  said 
with  all  possible  emphasis  that  these  temporary  teeth  should  be  pre- 
served against  decay  until  such  time  as  they  are  succeeded  by  the  per- 
manent teeth,  not  only  to  insure  against  abscesses,  but  for  the  pur- 
pose of  providing  the  developing  child  with  an  efficient  masticating 

*  See  International  Clinics,  Vol.  3,  page  77. 

(476) 


Mouth  Hygiene  and  its  Relation  to  Health  233 

apparatus.  How  often  is  one  told  that  because  these  are  temporary 
teeth  they  are  entitled  to  no  consideration,  with  the  result  that  their 
loss  is  looked  upon  with  indifference.  No  greater  mistake  could  be 
made,  for  it  means  not  only  an  unclean  and  diseased  mouth  at  a 
critical  period  in  the  life  of  the  child,  but  it  means  inevitable  irregu- 
larity of  the  permanent  teeth.  Abscesses  such  as  these  are  very 
common,  even  among  people  who  give  more  or  less  care  to  the 
hygiene  of  their  mouth.  In  their  chronic  form  they  cause  little  or 
no  pain ;  the  discharge  at  any  one  time  is  small,  and  their  presence  is 
viewed  with  unconcern.  As  a  result,  they  are  allowed  to  remain 
year  after  year,  discharging  their  poisonous  products  into  the 
mouth — only  one  of  the  several  agencies  which  contribute  to  its 
uncleanliness. 

Other  Factors  Which  Make  for  an  Unclean  Mouth.  Among 
the  other  causes  which  interfere  with  mouth  hygiene  may  be  men- 
tioned irregular  teeth,  ill-fitting  artificial  teeth,  salivary  tartar,  the 
habitual  use  of  tobacco,  etc.  If  for  no  other  reason  than  that  it 
contributes  to  mouth  hygiene,  teeth  that  are  markedly  irregular 
should  be  placed  in  their  normal  positions.  With  modern  facilities, 
this  can  be  done  without  in  the  least  interfering  with  the  health 
or  vocation  of  the  child.  Such  treatment  not  only  adds  greatly  to 
the  appearance,  but  renders  the  teeth  less  susceptible  to  decay. 

Because  people  are  prone  to  regard  artificial  substitutes  for 
teeth  quite  as  satisfactory  in  the  mastication  of  food  as  natural  ones, 
and  less  liable  to  cause  pain,  they  have  neglected  the  care  of  their 
own  teeth,  and  filled  their  mouth  with  all  manner  of  crowns,  bridges 
and  plates,  forgetting  that  with  each  addition  of  this  kind,  especially 
non-removable  appliances,  they  have  only  increased  the  difficulties 
in  the  way  of  a  clean  mouth.  By  actual  comparison  artificial  teeth 
have  been  found  to  be  ten  times  less  efficient  in  the  mastication  of 
food  than  are  sound  natural  teeth.  They  sustain  about  the  same 
relation  to  natural  teeth  that  a  wooden  leg  dbes  to  one  of  flesh 
and  bones.  Moreover,  their  esthetic  value  is  always  low.  Great 
care  should,  therefore,  be  exercised  to  preserve  one's  own  teeth,  not 
only  because  it  is  easier  to  keep  natural  teeth  clean,  but  because  of 
their  greater  efficiency  as  organs  of  mastication. 

If  no  other  charge  could  be  brought  against  the  habitual  use 
of  tobacco  other  than  that  it  contributes  to  the  uncleanliness  of  the 
mouth,  it  would  be  enough  to  condemn  its  use.    The  belief,  shared 

(477) 


234  The  Annals  of  the  American  Academy 

by  so  many,  that  it  preserves  the  teeth  against  decay  is  without 
foundation.  Its  effect  is  to  discolor  the  teeth,  to  add  to  the  general 
uncleanliness  of  the  mouth,  and  to  injure  the  gimis  and  mucous 
membrane  of  the  mouth  and  throat.  Smoking,  especially  pipe- 
smoking  is  the  most  common  cause  of  leucoplakia  of  the  mouth,  a 
disease  which  is  always  dangerous  because  of  its  tendency  to  break 
down  and  become  malignant. 

Some  of  the  Systemic  Effects  of  Mouth  Infection.  In  a  word, 
then,  decaying  teeth,  pyorrhea  alveolaris,  chronic  abscesses,  irregular 
teeth,  tobacco,  artificial  substitutes  for  teeth,  etc.,  are,  one  and  all. 
prejudicial  to  mouth  hygiene.  Moreover,  only  when  it  is  realized 
that  not  only  may  one,  two  or  three  of  these  agencies  of  filth  be 
present  in  any  given  mouth,  but  that  they  may  all  be  present  at  one 
and  the  same  time,  is  one  able  to  appreciate  the  possible  ill  effects  of 
such  conditions  upon  the  health  of  the  individual.  Some  of  the  ways 
in  which  the  pathogenic  organisms  of  the  mouth  gain  entrance  to  the 
body,  with  possible  serious  results,  may  be  enumerated  as  follows: 

1st.  Infections  caused  by  a  breach  in  the  continuity  of  the 
mucous  membrane  of  the  mouth,  brought  about  by  mechanical 
injuries,  wounds,  extractions,  etc.  These  lead  either  to  local  or 
general  disturbances. 

2d.  Infections  through  the  medium  of  gangrenous  tooth  pulps. 
These  usually  lead  to  the  formation  of  abscesses  at  the  point  of 
infection,  but  also  occasionally  to  secondary  septicemias  and  pyemia, 
with  fatal  termination. 

3d.  Disturbances  caused  by  the  resorption  of  poisonous  waste 
products  formed  by  bacteria. 

4th.  Pulmonary  diseases  caused  by  the  inspiration  of  particles 
of  slime,  small  pieces  of  tartar,  etc.,  containing  bacteria. 

5th.  Excessive  fermentative  processes  and  other  complaints  of 
the  digestive  tract  caused  by  the  continual  swallowing  of  microbes 
and  their  poisonous'products. 

6th.  Infections  of  the  intact  soft  tissues  of  the  oral  and  pharyn- 
geal cavities,  whose  powers  of  resistance  have  been  impaired  by 
debilitating  diseases,  mechanical  irritations,  etc- 

Nor  should  there  be  overlooked,  in  this  connection,  the  possi- 
bility of  an  infection  by  the  accumulation  of  the  excitants  of  diph- 
theria, typhus,  syphilis,  etc.,  within  the  mouth  tself.     That  the  rela- 

'^  "The  Micro-Organisms  of  the  Human  Mouth,"  P.  274. 
(478) 


Mouth  Hygiene  and  its  Relation  to  Health  235 

tion  existing  between  an  unclean  mouth  and  other  complaints  has  not 
long  ago  been  emphasized,  is  explained  by  the  fact  that  the  mouth,  as 
a  source  of  disease,  has  never  received  the  attention  which  its  impor- 
tance deserves,  and  though  there  are  some  who  at  present  recognize 
this  relation,  there  are  many  more  who  give  it  no  consideration 
whatever. 

In  the  introduction  to  his  book  on  "Oral  Sepsis  as  a  Cause  of 
Disease,"  William  Hunter,  M.  D.,  F.  R.  C.  P.,  has  this  to  say  relative 
to  the  influence  of  an  unclean  mouth  upon  the  health  of  the  body 
as  a  whole :  "I  desire  here  to  point  out  how  common  a  cause  of 
disease  it  is,  how  grave  are  its  effects,  how  constantly  it  is  over- 
looked, and  what  remarkably  beneficial  results  can  be  got  from  its 
removal.  What  I  wish  to  emphasize  is  that  it  is  not  the  stomatitis,  or 
the  dental  caries,  or  the  absence  of  teeth,  or  any  disturbance  of 
nutrition  in  connection  with  defective  teeth  that  causes  all  these 
effects.  The  condition  in  one  and  all  is  that  of  profound  sepsis; 
that  is  to  say,  we  are  dealing  with  pus- forming  organisms  which 
are  constantly  present  in  the  mouth  in  connection  with  necrosed 
teeth." 

He  sums  up  his  observations  regarding  the  influence  of  such 
conditions  upon  the  health  of  the  individual  in  the  following  words : 

(i)  The  condition  of  mouth,  associated  with  the  presence  of  decayed 
teeth  and  rotten  fangs,  is  not  simply  a  want  of  teeth,  but  is  a  condition  of 
profound  sepsis;  and  that,  too,  irrespective  of  any  pain  or  discomfort  they 
may  have  from  time  to  time  caused,  or  even  of  the  entire  absence  of  such 
pain. 

(2)  The  sepsis,  moreover,  is  one  differing  from  ordinary  surgical 
sepsis,  inasmuch  as  all  the  pus  organisms  are  continuously  being  swallowed, 
probably  over  a  period  of  many  years. 

(3)  Further,  it  is  a  sepsis  connected  with  diseased  bone  (».  e.,  tooth) 
than  which  there  is  no  more  virulent  form. 

(4)  While  the  gastric  juice  has  fortunately  a  great  capacity  for  killing 
organisms  this  capacity  is  not  complete  even  in  health,  in  the  intervals 
between  food  when  the  acidity  of  the  juice  is  at  a  minimum. 

(5)  The  continuous  influx  of  pus  organisms  from  diseased  teeth  and 
gums  must  be  a  source  of  disturbance  to  the  mucosa,  causing  catarrh  and 
diminished  gastric  secretion. 

(6)  When  we  have  diminished  acidity  of  gastric  juice,  with  increased 
influx  of  organisms,  we  have  the  two  conditions — diminished  resisting  power 
and  increase  of  dose — which  all  pathological  knowledge  shows  to  be  the  two 
chief  conditions  underlying  infection. 

(479) 


236  The  Annals  of  the  American  Academy 

(7)  Consequently,  the  gastric  catarrh  becomes  really  a  septic  catarrh, 
due  to  invasion  of  the  mucosa  with  septic  organisms. 

(8)  Further,  apart  altogether  from  its  gastric  effects,  a  continued  pro- 
duction of  pus  in  the  mouth  must  be  a  source  of  danger  in  other  ways. 

(9)  The  mere  septic  absorption  from  such  teeth  and  gums  must  be  very 
considerable,  lasting  as  it  does  over  many  years. 

(10)  The  sallow  look  and  languid  feelings  of  which  the  patient  com- 
plains, and  which  he  and  his  physicians  agree  in  referring  to  his  chronic 
indigestion,  are  really  the  expression  of  this  septic  absorption. 

(11)  If  pus  organisms  are  constantly  being  swallowed  there  is  a  risk 
of  their  infecting  the  tonsil  over  which  they  must  pass,  and  hence  tonsillitic, 
pharyngeal  and  Eustachian  tube  infection  may  from  time  to  time  occur. 

(12)  Even  apart  from  such  local  effects  there  must  always  be  a  cer- 
tain risk  connected  with  the  absorption  into  the  blood  of  such  organisms 
from  f ungating  gums  around  diseased  teeth ;  and,  if  other  conditions  are 
favorable,  there  may  be  infection  from  the  blood — c.  g.,  ulcerative  endo- 
carditis, empyemata,  meningitis,  osteomyelitis,  etc, 

(13)  In  short,  while  every  care  has  been  and  is  being  taken  in  increas- 
ing degree  to  protect  the  public  from  notorious  disease-producing  organisms, 
such  as  typhoid  or  tubercle  bacilli,  whether  in  the  air  it  breathes,  the  food  it 
takes,  the  water  it  drinks ;  and  the  utmost  care  is  even  taken  by  habits  of 
cleanliness  or  stringent  surgical  precautions  to  protect  any  introduction  of 
ordinary  septic  organisms  by  the  skin — the  mouth  alone  is  disregarded  and  the 
patient  is  left  with  a  permanent  condition  of  sepsis,  which,  did  it  exist 
in  any  other  part  of  the  body,  would  at  once  receive  immediate  attention. 

Regarding  the  influence  of  mouth  sepsis  upon  the  respiratory 
apparatus,  Wadsworth  says :  ^  "From  the  hygienic  standpoint,  the 
secretions  of  the  mouth  constitute  the  chief,  if  not  the  only,  source  of 
respiratory  infections,  and  this  infectious  material  is  transferred 
from  one  person  to  another,  in  some  cases  through  the  air,  as  from 
sneezing  or  coughing,  and  to  an  even  more  serious  extent  by  per- 
sonal contact,  or  by  the  use  in  common  of  the  various  accessories 
of  life." 

The  Prevention  of  Mouth  Diseases.  To  cure  disease  has  been 
characterized  as  the  voice  of  the  past ;  to  prevent  it  as  the  divine 
whisper  of  the  present. 

People  are  everywhere  coming  to  tinderstand  that  most  of  the 
diseases  affecting  mankind  are,  to  a  considerable  extent,  preventable 
diseases,  and  are  turning  deaf  ears  toward  the  voice  of  the  past, 
while  intently  listening  to  the  whispered  voice  of  the  present. 

Prevention  of  Caries.     Perhaps  in  nothing  is  the  ounce  of  pre- 
vention of  more  value  than  in  the  treatment  of   dental  diseases. 
» Infectious  Diseases.    Oct.,  1906. 

(480) 


Mouth  Hygiene  and  its  Relation  to  Health  237 

Just  how  far  caries  of  the  teeth  can  be  prevented,  it  is  impossible 
to  say. 

There  are  individuals  who  are  immune  in  spite  of  neglect,  just 
as  there  are  individuals  whose  teeth  decay,  because  of  a  high  sus- 
ceptibility, in  spite  of  every  care,  clearly  proving  that  there  are 
other  factors  than  cleanliness  to  be  considered  in  the  prevention  of 
the  Peoples'  Disease." 

There  is  one  thing,  however,  which  may  be  regarded  as  axio- 
matic— the  cleaner  is  the  mouth,  the  less  subject  will  the  teeth  be 
to  decay,  other  things  being  equal.  Dr.  Ch.  L.  Quincerot  *  says  on 
this  point:  "Etiologically,  an  unclean  condition  of  the  oral  cavity 
is  the  principal  factor  in  the  production  of  dental  caries.  While 
admitting  that  a  certain  number  of  predisposing  factors,  such  as 
sex,  age,  constitution,  heredity  and  defects  of  structure,  aggravate 
the  production  of  caries,  in  the  majority  of  cases  uncleanliness  is 
the  initial  cause," 

In  the  prevention  of  caries,  obviously,  the  first  requisite  is  a 
clean  mouth.  To  accomplish  this,  the  teeth  should  be  brushed  with 
a  carefully  selected  brush,  at  least  twice  daily,  with  a  dentifrice 
the  ingredients  of  which  are  known.  Too  many  people  are  willing 
to  use  a  dentifrice  solely  on  the  recommendation  of  the  manufac- 
turer, who  probably  knows  nothing  of  what  is  required  in  such  a 
preparation,  and  whose  only  interest  is  in  the  profits. 

Most  of  the  toothbrushes  upon  the  market  are  poorly  adapted  to 
the  proper  cleansing  of  the  mouth  and  teeth,  being  too  large  and  of 
improper  shape.  A  small  brush  of  good  quality  and  medium  stiff- 
ness should  be  employed.  The  teeth  should  be  brushed  in  an  up- 
and-down  direction,  never  across,  allowing  the  brush  to  pass  well  up 
over  the  gums  on  the  external  surface  of  all  the  teeth.  The  mouth 
should  then  be  opened,  and  the  grinding  surfaces  of  the  teeth  thor- 
oughly brushed,  especial  care  being  given  to  those  in  the  back  part 
of  the  mouth.  Then,  by  tilting  the  brush,  cleanse  the  inner  surfaces 
of  the  teeth,  again  allowing  the  brush  to  come  against  the  gums  in 
the  form  of  a  massage.  The  tongue  should  then  be  extended  from 
the  mouth  and  carefully  brushed.  After  meals,  whenever  possible, 
the  mouth  should  be  flushed  with  warm  water  and  the  teeth  brushed, 
for  the  purpose  of  removing  particles  of  food.  The  waxed  silk,  or, 
better,  the  waxed  silk  tape  more  recently  placed  on  the  market, 

*  Le  Monde  Dontftiro,  Paris,  Jan.,   1900. 

(481) 


238  The  Annals  of  the  American  Academy 

should  be  passed  back  and  forth  between  the  teeth,  not  only  for 
the  purpose  of  removing  particles  of  food  which  may  have  wedged 
between  them,  but  for  the  purpose  of  breaking  up  the  small  ge- 
latinous plaques  which  form  in  these  spaces,  and  under  cover  of 
which  the  micro-organisms  carry  on  their  tooth-destroying  activities. 

The  busy  man  will  raise  the  objection  that  all  this  takes  time. 
So  it  does,  and  so  does  anything  that  is  worth  while.  But  it  will 
also  save  time.  To  prevent  teeth  from  decaying  will  always  con- 
sume less  time  than  does  the  repairing  of  them.  Moreover,  it  will 
pay  100  per  cent,  in  comfort,  health  and  masticating  efficiency,  not 
to  mention  the  saving  in  dental  bills.  It  is  not  half  so  much 
reparative  dentistry  that  the  public  is  in  need  of  to-day  as  it  is 
preventive  dentistry. 

Another  potent  factor  in  tooth  decay  is  the  lack  of  exercise 
given  the  teeth  in  mastication.  One  has  only  to  observe  the  people 
in  a  public  dining-room  to  be  impressed  with  how  little  real  use 
is  made  of  the  teeth.  The  way  in  which  food  is  now  prepared  has 
much  to  do  with  this,  but  decaying  teeth,  lack  of  teeth,  and  habit 
have  more.  Good,  vigorous  use  of  the  teeth  in  the  mastication  of 
food  not  only  goes  a  long  way  toward  keeping  them  clean,  but  it  also 
adds  appreciably  to  their  immunity  from  decay. 

Viewed  solely  in  its  relation  to  mouth  hygiene,  the  gospel  of 
physiological  mastication,  so  ably  preached  by  Horace  Fletcher,  is 
one  which  could  be  practiced  by  every  one  with  increasing  benefit. 
A  high  standard  of  health  will  also  operate  in  reducing  the  suscep- 
tibility to  caries  of  the  teeth. 

It  must  not  be  inferred  from  the  foregoing  that  caries  of  the 
teeth  can  be  entirely  prevented.  Unfortunately,  we  can  only  hope  in 
cases  of  great  susceptibility  to  limit  the  disease.  The  family  dentist 
will  still  remain  a  family  necessity,  but  his  services  should  be  sought 
not  alone  for  the  purpose  of  repairing  the  devastating  effects  of 
this  disease,  but  as  a  supplemental  aid  in  its  prevention.  Caries,  like 
most  of  the  other  diseases  of  the  mouth,  can,  in  its  incipiency,  be 
easily  and  effectually  arrested,  and  this  without  in  the  least  impair- 
ing the  usefulness  of  the  teeth  as  organs  of  mastication,  hence  the 
importance  of  discovering  its  presence  early.  Until  the  laws  govern- 
ing susceptibility  and  immunity  to  disease  are  better  understood 
than  they  are  at  present,  frequent  visits  to  the  dentist  in  the  interest 
of  prevention  should,  therefore,  be  encouraged. 

(482) 


Mouth  Hygiene  and  its  Relation  to  Health  2^g 

Pyorrhea  Alveolaris — Its  Prevention:  Like  caries  of  the  teeth, 
pyorrhea  alveolaris  can,  to  a  considerable  extent,  be  prevented, 
providing  proper  attention  is  given  to  mouth  hygiene.  In  fact, 
its  prevention  is  more  certain  than  is  that  of  caries.  Its  causes  are 
many ;  among  them  being  irritation  at  the  free  margin  of  the  gums, 
wedging  of  food  between  the  teeth,  tartar,  poorly  fitting  artificial 
crowns,  general  uncleanliness  of  the  mouth,  overuse  or  disuse  of 
the  teeth,  irregular  teeth  and  certain  systemic  conditions  which  pre- 
dispose to  the  disease. 

Its  progress  is  slow,  and  in  its  beginning  it  is  easily  cured.  In 
fact,  it  may  be  said  to  be  always  curable  so  long  as  there  remains 
sufficient  tissue  to  support  the  teeth  after  the  disease  has  been 
eradicated.  This  is  emphasized  here  because  it  is  so  often  said 
to  be  incurable,  and  so  often  believed  to  be  true.  Its  influence  upon 
the  health  is  always  bad,  though  not  always  obvious. 

The  Chronic  Abscess — Its  Prevention.  The  chronic  alveolar 
abscess,  above  described,  could  be  entirely  prevented  if  decay  of  the 
teeth  was  checked  in  its  incipiency — a  further  argument  in  favor  of 
early  treatment  where  prevention  fails.  A  living  tooth  will  never 
become  the  seat  of  an  abscess.  Only  "dead  teeth  ulcerate."  Under 
no  circumstances  should  their  presence  be  tolerated,  as  their  cure  is 
usually  not  difficult. 

The  Dental  Needs  of  School  Children.  As  decay  of  the  teeth  is 
peculiarly  a  disease  of  childhood,  manifesting  itself  as  early  as  the 
third  year,  so  it  is  the  most  common.  Practically  no  child  escapes 
its  ravages.  It  may,  therefore,  be  said  without  fear  of  contradic- 
tion that  the  average  person  who  has  given  no  attention  to  mouth 
hygiene  is,  at  twenty  years  of  age,  from  a  dental  standpoint,  a  lost 
cause.  Certain  it  is  that  he  will  already  have  lost  several  teeth, 
while  others  will  have  become  so  weakened  by  long-neglected  decay 
as  to  render  the  hope  of  permanently  saving  them  extremely  doubtful. 
The  following  case  will  serve  to  illustrate  this  point :  While  engaged 
in  writing  the  foregoing  paragraph,  there  was  sent  to  the  author 
by  the  Charity  Organization  Society  of  this  city  a  girl  of  nineteen, 
for  examination  and  advice  as  to  what  should  be  done  for  her  in  the 
way  of  mouth  hygiene.  An  examination  of  her  mouth  revealed  the 
fact  that  she  had  already  lost  seven  teeth  through  extraction  (two 
of  them  being  the  upper  central  incisors),  while  the  decaying  roots 
of  five  others  were  all  that  was  visible  above  the  gum  line,  meaning 

(483) 


240  The  Annals  of  the  American  Academy 

that  ill  any  course  of  treatment  these  must  also  be  extracted.  In  the 
remaining  sixteen  teeth  (for  the  "wisdom  teeth"  had  not  yet  erupted), 
there  were  twenty-two  carious  cavities  requiring  immediate  atten- 
tion if  these  teeth  were  to  be  saved.  The  whole  mouth  was  foul  in 
the  extreme,  the  patient  admitting  that  she  did  not  use  a  toothbrush, 
as  in  their  present  condition  the  teeth  were  so  sensitive  as  to  make 
its  use  extremely  painful,  which  was  probably  true.  Some  of  the 
evil  consequences  of  this  long-continued  neglect  were  already  ap- 
parent, in  the  highly  inflamed  gums-,  enlarged  tonsils  and  cervical 
lymph  nodes,  and  in  the  ashy  pallor  so  characteristic  of  mouth  infec- 
tion. Assuming  that  this  girl  could  now  avail  herself  of  all  that 
modern  dentistry  could  give,  her  loss  would  still  be  an  irreparable 
one.  And  when  one  considers  the  necessary  time,  expense  and  pain 
involved  in  such  treatment,  and  compare  it  with  the  small  expense 
and  practically  no  pain  attendant  upon  preventive  treatment  per- 
sisted in  from  childhood,  a  treatment  which  would  have  insured 
against  the  loss  of  a  single  tooth,  the  value  of  early  treatment  cannot 
but  be  apparent  to  all.  This  is  no  exceptional  case.  Perhaps  no 
better  proof  of  this  could  be  given  than  that  furnished  by  a  report 
of  an  examination^  made  of  five  hundred  public  school  children 
applying  to  the  Board  of  Health  in  New  York  City  for  their  mercan- 
tile certificates  in  the  spring  of  1909.  These  children  represented  a 
large  number  of  the  public  schools  of  the  city,  and  it  is  probable 
that  the  condition  of  their  mouths  was  fairly  indicative  of  that  which 
prevails  throughout  the  schools  of  the  city.  It  was  found  that  not 
one  had  what  might  be  regarded  as  a  decently  clean  mouth.  Four 
hundred  and  eighty-six  of  their  number  had  decaying  teeth,  642  of 
which  had  already  been  extracted,  or  were  so  badly  decayed  as  to 
make  extraction  necessary.  There  were  2808  decaying  teeth  in  their 
mouths,  many  of  which  could  only  be  saved  by  prompt  attention. 
But  twenty-five  of  their  number  had  ever  been  to  a  dentist  except 
for  tooth  extraction.  The  use  of  the  toothbrush  was  practically 
unknown  among  them.  And  this,  it  must  be  remembered,  among 
children  the  oldest  of  whom  was  but  sixteen  years  of  age.  Investi- 
gations made  in  other  cities  would  seem  to  indicate  that  these  figures 
are  fairly  representative  of  the  dental  needs  of  the  children  in  our 
public  schools  throughout  the  country. 

Effects  of  Mouth  Infection  Upon  Child  Life.     As  it  is  the  child 

»By  Wallace  T.  Van  Winkle,  D.D.S.,  N.  Y. 

(484) 


Mouth  Hygiene  and  its  Relation  to  Health  241 

who  is  most  susceptible  to  caries  of  the  teeth,  so  it  is  the  child  who 
is  the  greatest  sufferer,  and  not  only  is  this  true  regarding  the  local 
effect  of  caries,  but  especially  is  it  true  of  its  influence  upon  the 
health  and  efficiency  of  the  developing  child.  Of  the  effects  of 
mouth  infection  upon  the  health  of  the  child,  Henry  G.  Lang- 
worthy,  M.  D.,®  says :  "Contamination  of  food  is  important  in  caus- 
ing decay  of  food  within  the  body,  the  poisons  of  which  frequently 
cause  secondary  gastric  catarrh,  various  forms  of  auto-intoxication, 
anemia,  nervous  debility  and  appendicitis.  A  foul  mouth  and  de- 
caying teeth,  particularly  in  children,  decidedly  increase  the  chances 
of  catching  such  contagious  and  infectious  diseases  as  scarlet  fever, 
diphtheria,  measles  and  tuberculosis.  A  clean  mouth  will  do  much 
to  prevent  tubercle  bacilli  from  gaining  a  foothold  in  the  body." 
Not  less  than  40  per  cent  of  the  absentees  from  school  are  caused  by 
toothache  or  other  equally  preventable  dental  ills  and  their  sequelae.'' 
In  a  public  address  made  before  the  Dental  Hygiene  Conference 
held  in  New  York  City  in  May,  1910,  Luther  H.  Gulick,  M.  D., 
formerly  physical  director  of  the  public  schools,  and  at  present  head 
of  the  Division  of  Child  Hygiene  in  the  Russell  Sage  Foundation, 
said  that  investigation  had  shown  that  it  takes  children  with  defect- 
ive teeth  at  least  six  months  longer  to  complete  the  eight  common- 
school  grades  than  it  does  those  without  defective  teeth.  Such 
observations  have  been  made  by  other  investigators. 

Need  of  Public  Dental  Dispensaries.  One  thing  is  certain:  If 
the  teeth  of  the  present  generation  are  to  be  saved,  it  must  be  done 
during  their  school  life.  To  defer  it  until  they  have  taken  upon 
themselves  the  responsibilities  of  adult  life  will  be  too  late.  Caries 
will  already  have  done  its  work.  What  per  cent,  of  the  parents 
of  the  children  in  our  public  schools  are  able  to  provide  adequate 
dental  treatment  for  their  children  when  taught  its  value,  no  one  can 
tell.  But  whatever  it  may  be,  there  will  inevitably  remain  a  vast 
multitude  of  children  who  must  depend  upon  the  dispensary  for  all 
needed  dental  treatment.  And,  curiously  enough,  there  are  at 
present  no  such  dispensaries.  Scarcely  a  hospital  in  the  United 
States  has  an  adequately  equipped  dental  department.  It  is  true 
there  are  a  few  dental  clinics  in  some  of  our  larger  cities,  which 

•Dental  Cosmos.     Vol.  51,  page  705. 

»John  J.  Cronin,  M.D.,  Asst.  Chief  Med.  Insp.  Dlv.  Child  Hygiene.     Board  of 
Health  N.  Y.  City. 

(485) 


242  The  Annals  of  the  American  Academy 

have  sprung  into  being  within  the  past  few  years,  but  not  one  of 
them  is  equipped  to  meet  the  needs  of  the  community  in  which  it 
is  located,  unless  we  except  the  one  being  built  in  Boston,  and  made 
possible  by  the  Forsythe  gift  of  $1,200,000.  There  is  not  a  city  in 
the  United  States  which  does  not  need  such  a  dispensary  to  meet 
the  needs  of  the  children  in  its  own  public  schools.  Germany  has 
already  recognized  this  need,  and  made  provisions  to  meet  it  by  the 
establishment  of  free  dispensaries  in  upward  of  thirty  of  its  cities, 
where  free  dental  treatment  is  furnished  to  the  children  of  the  public 
schools.  In  most  instances  these  are  supported  by  the  municipalities 
in  which  they  are  located. 

The  Need  of  Co-operation.  Obviously,  the  first  step  toward 
the  achievement  of  this  much-needed  reform  in  the  United  States 
is  the  education  of  the  public  in  matters  affecting  the  health  of  the 
mouth,  with  a  view  to  limiting  the  spread  of  dental  diseases,  as  far 
as  that  is  possible  through  preventive  measures,  and  the  arrest  of 
such  as  are  not  prevented  by  early  treatment.  The  responsibility 
for  the  inauguration  of  such  a  campaign  rests  squarely  upon  the 
shoulders  of  the  dental  profession.  It  is  they  who  know  better  than 
any  other  group  of  men  the  value  of  a  clean  mouth  in  its  relation 
to  health.  As  a  result,  there  is  scarcely  a  dental  organization 
throughout  the  country — national,  state  or  local — in  which  an  organ- 
ized effort  is  not  being  made  to  spread  the  gospel  of  clean  mouths. 
But  this  is  not  enough.  As  a  public  health  measure,  the  problem  is 
unlike  any  other  ever  before  offered  for  consideration.  The  univer- 
sality of  the  disease,  the  vast  numbers  involved,  the  rapidity  with 
which  caries  causes  the  destruction  of  the  teeth,  especially  in  child- 
hood ;  the  amount  of  time  involved  in  dental  operations  all  conspire 
to  make  its  solution  a  difficult  one.  They  must  have,  in  this  cam- 
paign, the  co-operation  of  every  one  who  has  to  do  with  child  life — 
parent,  teacher,  physician,  nurse,  social  worker — wherever  he  or  she 
may  be,  throughout  the  length  and  breadth  of  the  land.  Nor  is  this 
enough.  It  is  absolutely  essential,  if  any  adequate  step  is  ever  taken 
to  meet  this  need,  that  they  have  the  co-operation  of  the  municipality, 
state  and  nation,  for  it  is  only  through  such  co-operation  that  they 
can  ever  hope  successfully  to  cope  with  the  appalling  conditions 
existing  among  the  children  of  our  public  schools. 


(486) 


THE  PHYSICAL  CARE  OF  CHILDREN 


By  Walter  S.  Cornell,  M.D., 

Neurologist   to   the   Division   of    School    Inspection,   Department    of    Public 

Health  and  Charities,  Philadelphia. 


The  physical  care  of  children  has  developed  from  the  aca- 
demic subject  of  school  hygiene  taught  by  pedagogues,  with  in- 
accurate knowledge  and  weak  force,  into  several  well-developed 
specialized  lines  of  work,  each  an  active  force.  Chief  among 
these  are  the  medical  inspection  of  school  children,  the  provision 
of  playgrounds  and  free  medical  treatment,  and  the  enactment  of 
laws  calculated  to  prevent,  or  at  least  decrease,  child  labor. 

Taking  up  these  subjects  seriatim,  and  considering  first  the 
medical  inspection  of  children  in  the  schools,  we  find  its  reason 
for  existence  in  the  fact  that  the  eight  years  of  school  life  oflFer 
the  only  opportunity  to  the  community  to  examine  all  its  mem- 
bers. Such  inspection  has  a  double  interest,  that  of  the  physical 
health  of  the  community  and  that  of  the  intelligence  of  the  com- 
munity, since  doctors  have  come  to  realize  that  physical  health 
is  a  strong  factor  for  or  against  mental  development. 

The  medital  inspection  of  school  children  was  first  insti- 
tuted in  America,  on  a  large  scale,  by  the  health  department  of 
the  city  of  New  York,  which,  in  1905,  appointed  medical  inspec- 
tors to  examine  all  of  the  school  children  of  the  city,  I  am  glad 
to  say  that  the  first  honor  of  medical  inspection  apparently  be- 
longs to  my  own  city  of  Philadelphia,  whose  board  of  education 
many  years  ago,  at  the  instance  of  Dr.  Samuel  D.  Risley,  com- 
missioned him  and  three  other  physicians  to  test  the  vision  of 
the  children  in  the  schools.  Unfortunately,  however,  a  certain 
opposition  developed  on  the  part  of  the  parents,  and  for  want 
of  vigorous  championship  the  work  was  allowed  to  drop.  Since 
that  time,  in  various  cities,  directors  of  school  inspection  have 
succeeded  in  having  the  work  done  upon  a  small  scale ;  but  the 
comprehensive  system  instituted  in  New  York,  which  has  already 
been  mentioned,  marks  the  first  noteworthy  and  permanent  step 
along  this  line. 

(487) 


244  'The  Annals  of  the  American  Academy 

That  there  is  reason  for  medical  inspection  is  easily  shown 
by  the  numerous  statistics  compiled  by  the  examiners  of  children ; 
the  figures  here  given  may  be  accepted  without  hesitancy  by  the 
reader.  Eye  strain  exists  in  about  twenty-five  to  thirty  per  cent, 
of  all  school  children,  meaning  by  eye  strain,  all  cases  of  defective 
vision  from  refractive  error,  and  those  cases  of  normal  vision  in 
which  such  vision  is  accomplished  only  by  labored  effort  and 
headaches  and  tiring  over  the  eyes.  The  simple  test  of  medical 
inspection  procured  detailed  statements  of  hyperopia,  myopia,  as- 
tigmatism and  muscular  insufficiency. 

Diseases  of  the  nose  and  throat  exist  numerously  in  young 
children,  particularly  those  of  the  poorer  classes,  whose  unhy- 
gienic home  surroundings  act  as  predisposing  causes.  Of  these 
defects,  nasal  obstruction  (mostly  by  adenoids)  exist  in  from 
six  to  twenty-five  per  cent,  of  the  school  children,  according  to 
the  age  and  social  condition,  younger  children  and  poorer  children 
being  those  most  affected.  The  large  tonsils,  which  are  fre- 
quently associated  with  adenoids,  and  which  really  signify 
chronic  inflammation,  as  well  as  enlargement,  are  found  in  from 
three  to  ten  per  cent,  of  school  children,  the  number  depending 
upon  the  factors  just  noted  in  connection  with  nasal  obstruction. 
Defective  hearing  exists,  in  one  ear  at  least,  in  about  five  per 
cent,  of  all  children ;  such  prevalence,  however,  being  quite  vari- 
able at  different  times,  owing  to  the  fact  that  the  catarrh,  which 
usually  causes  deafness,  is  more  prevalent  at  some  seasons  than 
others. 

Decayed  teeth  are  very  numerous  in  young  children,  par- 
ticularly those  of  the  poor,  who  do  not  know  a  tooth  brush  and 
whose  nutrition  is  low;  and  over  two-thirds  of  the  children  be- 
tween the  ages  of  seven  and  nine  years  possess  such  defects. 
Defects  of  the  tenth  year,  or  temporary  teeth,  are  less,  and  chil- 
dren for  a  brief  period  present  but  little  dental  decay  until  the 
thirteenth  or  fourteenth  year  is  reached,  when  permanent  teeth 
begin  to  break  down,  also.  Among  the  older  grammar  children, 
twenty-five  or  thirty  per  cent,  show  carious  teeth. 

Among  the  orthopaedic  defects,  stoop  shoulders  and  lateral 
curvature  of  the  spine  command  attention,  because  of  their  great 
frequency.  Stoop  shoulders,  with  its  associated  flat  chest,  are 
usually  due  to  defective  vision  or  defective  hearing,  which  causes 

(488) 


The  Physical  Care  of  Children  245 

the  child  to  lean  forward  to  see  and  hear;  to  nasal  obstruction 
and  poor  nutrition,  which  rob  the  child  of  vitality  and  cause  it 
to  slouch  as  it  sits ;  and  to  ill-fitting  school  desks  and  seats.  Lat- 
eral curvature  is  an  extremely  common  defect,  but  usually  exists 
in  but  small  degree. 

Nervous  disorders  include,  principally,  chorea,  which  is  the 
most  manifest  evidence  of  increased  sensitiveness,  quick  fatigue 
and  poor  emotional  control,  which  are  the  fundamental  conditions 
underlying  an  exhausted  nervous  system.  Poor  nutrition  exists 
largely,  but  not  according  to  the  statements  of  the  investigator. 
Many  statements,  which  have  appeared  in  magazines  and  news- 
papers to  the  effect  that  thousands  of  children  are  in  a  condition 
of  semi-starvation,  are  doubtless  exaggerations,  but  no  one  who 
has  been  in  actual  contact  with  the  children  of  the  poor  foreign 
districts  of  a  great  city  fails  to  recognize  that,  regardless  of  the 
actual  weight  and  height  of  such  children,  they  show  a  decided 
lack  of  vigor  and  flabbiness  of  tissue,  due  to  the  use  of  improper 
food. 

Correction  of  these  defects  just  enumerated  has  proceeded 
so  far  by  reason  of  the  efforts  of  medical  inspectors,  appointed 
either  by  the  health  or  educational  authorities,  with  the  assist- 
ance, in  many  cases,  of  social  visitors  (usually  nurses),  and  the 
valuable  assistance  of  free  medical  and  dental  treatment.  The 
physical  education  of  children,  and  the  institution  of  playgrounds 
and  recreation  centers,  may  also  be  considered  as  important  aids 
in  this  work,  but  so  far  they  have  had  but  little  direct  relation  with 
the  work  of  medical  inspection. 

Arguments  bearing  upon  the  proper  appointive  power,  salary, 
hours  of  service,  tenure  of  office,  and  special  training  of  medical 
inspectors  are  exceedingly  interesting  and  important  to  those 
directly  concerned  in  the  carrying  on  of  this  work,  but  are  too 
administrative  in  character  to  receive  attention  here. 

The  object  of  medical  inspection  is  two-fold.  First,  the 
prevention  of  contagious  diseases;  and,  second,  the  correction 
of  existing  physical  defects.  The  latter,  it  will  be  noted,  par- 
takes at  the  same  time  of  the  character  of  corrective  and  pre- 
ventive medicine,  since  the  early  correction  of  a  physical  defect 
signifies,  in  many  cases,  the  prevention  of  a  secondary  one. 

It  is  interesting  to  note  that  the  medical  inspection  of  the 

(489) 


246  The  Annals  of  the  American  Academy 

New  York  school  children  was  originally  planned  by  Doctor 
Darlington,  as  a  measure  for  the  saving  of  school  time  for  those 
children  who  are  excluded  from  school  by  reason  of  minor  con- 
tagious diseases;  the  reasoning  being  that  the  exclusion  of  a 
child  for  uncleanliness,  pediculosis,  ring  worm,  etc.,  is  neces- 
sary; but,  if  carelessly  done  by  the  authorities,  is  a  source  of 
long  absence  from  school.  The  realization  that  the  correction  of 
physical  defects  is  much  more  important  than  the  cure  of  minor 
parasitic  diseases  came  to  the  authorities  subsequent  to  the 
actual  introduction  of  medical  inspection. 

The  actual  work  of  medical  inspection  is  conducted  by  as- 
signing to  each  inspector,  in  the  case  of  the  schools  of  a  large 
city  at  least,  a  certain  number  of  schools.  Over  these  schools 
he  exercises  jurisdiction  as  health  officer,  occasionally  excluding 
children  suffering  from  contagious  diseases ;  daily  examining,  at 
the  request  of  teachers,  children  suspected  by  the  latter  of  vari- 
ous physical  defects ;  and,  finally,  examining  each  child  in  his 
group  of  schools  in  a  systematic  manner,  so  that  defects  of  the 
eye,  ear,  nose,  throat,  teeth,  skeleton,  skin  and  nervous  system 
are  found.  The  number  of  children  assigned  to  one  inspector 
may  roughly  be  set  down  as  from  four  to  five  thousand.  The 
children  in  the  slum  districts  need  more  medical  inspectors  than 
those  in  the  better  residence  districts.  It  is  the  custom,  in 
Philadelphia  at  least,  for  the  inspector  to  visit  all  of  his  schools 
every  morning,  stay  a  short  time  at  each  to  examine  any  inci- 
dental cases  brought  to  his  attention,  and,  at  the  last  school 
visited,  to  systematically  examine  twenty  children.  By  this 
means,  in  a  school  year  of  two  hundred  days,  four  thousand 
children  are  systematically  examined.  It  may  be  noted  that 
this  is  a  maximum  figure,  since  the  month  of  September  is  largely 
consumed  in  examining  vaccination  marks  of  new  children,  and 
the  month  of  June  naturally  marks  the  cessation  of  health  ac- 
tivities, because  of  approaching  examinations. 

The  method  of  examination  pursued  by  a  medical  inspector 
in  a  systematic  examination  of  children  is  worth  noting.  The 
child  is  first  asked  to  read  the  letters  on  the  test  card  for  vision, 
and  his  acuity  of  vision,  as  well  as  the  frequent  existence  of  head- 
ache and  eye-tire  is  noted.  If  the  child  shows  a  squint,  or  if 
he  wears  eyeglasses,  these  facts  are  noted  also.    The  examination 

(490) 


The  Physical  Care  of  Children  247 

of  the  nose  and  throat  and  of  the  freedom  in  nose  respiration  is 
next  made,  together  with  an  inspection  of  the  teeth.  Following 
this,  the  heart  is  tested,  usually  by  means  of  a  watch  in  the  hands 
of  the  examiner,  the  child's  eyes  being  in  the  meanwhile  closed. 
Poor  nutrition  is  detected  by  general  inspection,  and  the  child's 
manner  of  answering  and  general  demeanor  suffices,  by  necessity, 
for  the  detection  of  a  run-down  nervous  system. 

The  clerical  and  administrative  work  following  the  exam- 
ination of  children  consists  in  the  recording  of  the  defects  found, 
and  the  institution  of  measures  looking  to  their  correction. 

The  matter  of  record  keeping  is  extremely  important,  since 
the  systematic  and  business-like  conduct  of  any  work  under- 
taken on  a  large  scale  is  vital.  Medical  inspection  records  are 
essentially  of  three  kinds:  The  child's  individual  record,  show- 
ing his  physical  condition ;  a  list  of  the  defective  children  in  the 
school,  together  with  the  defects  found ;  and  a  summary,  or  re- 
port, of  the  defects  found  and  work  done. 

As  to  the  child's  individual  record,  it  is  essential  that  this 
record  should  accompany  him  throughout  his  school  life,  so  that 
teacher,  parent  and  inspector  may  be  kept  aware  of  his  physical 
condition,  and,  in  the  event  of  sickness  and  poor  scholarship,  be 
apprised  of  the  physical  defect  which  so  often  has  caused  these 
troubles.  It  is  unfortunate  at  the  present  time  that  our  school 
authorities  do  not  recognize  the  value  of  these  records  along 
the  lines  just  mentioned.  For  it  is  certain  that  not  one  teacher 
in  twenty  has  any  idea,  after  medical  inspection  of  her  class,  as 
to  which  children  have  been  found  defective  and  which  have 
not.  Possibly  the  day  will  come  when  teachers  are  compelled 
to  be  familiar  with  the  physical  condition  of  every  child,  and 
supervising  principals  will  understand  that  "supervision"  means 
the  knowledge  of  the  health  and  home  environment  of  every 
backward  or  delinquent  child,  with  a  responsibility,  for  the  en- 
deavor at  least,  to  correct  such  conditions. 

The  record  cards  should  contain  the  record  of  physical  ex- 
aminations made  yearly  or  biennially  or  triennially,  as  the  case 
may  be,  and  the  record  of  each  examination  should  carry  with  it, 
not  only  the  defects  found,  but  the  date  on  which  the  parents 
were  notified  of  the  existence  of  the  defect,  and  whether  or  not 
such  defect  was  corrected  by  them.    In  this  way,  quick  reference 

(491) 


248  The  Annals  of  the  American  Academy 

can  be  had  to  the  whole  matter,  and  at  the  time  of  the  second 
examination  of  the  child  the  inspector  knows  at  once,  by  reason 
of  the  record,  whether  the  child  has  been  found  defective,  and 
whether  or  not  the  parents  are  careful  or  neglectful. 

The  correction  of  physical  defects  found  by  the  medical  in- 
spector has  been,  up  to  the  present  time,  optional  on  the  part 
of  the  parents,  and  it  is  worthy  of  note,  therefore,  that  the  official 
methods  of  correction  are  only  those  of  persuasion.  Possibly  the 
day  will  come  when  cases  of  flagrant  parental  neglect,  such  as 
the  failure  to  properly  feed  poorly  nourished  children,  to  provide 
eyeglasses  for  a  squinting  child,  or  procure  medical  treatment 
for  a  bad  case  of  adenoids,  with  its  train  of  secondary  effects, 
will  be  the  basis  of  prosecution  by  the  legal  officers  of  the  com- 
munity. Certain  it  is  that  a  puddle  in  the  back  alley,  which 
may  be  proceeded  against  as  a  nuisance,  or  the  keeping  of 
chickens  in  a  cellar,  which  may  be  the  basis  of  complaint  by 
the  Society  for  Prevention  of  Cruelty  to  Animals,  do  not  compare 
in  their  injurious  effects  with  the  presence  of  a  serious  defect  in 
a  child,  which  daily  lowers  its  vitality,  dulls  its  vision,  or  per- 
manently blemishes  its  personal  appearance. 

The  method  of  correction  has  principally  been  by  means  of 
parents'  notices,  which  are  most  efficient  when  specific  in  char- 
acter. These  special  notices  for  eye-strain,  nasal  obstruction, 
decayed  teeth  and  stoop  shoulders  produce  results  because  of 
the  warning  information  attached,  when  a  simple  blank  form, 
merely  specifying  the  defect,  fails  of  its  purpose.  However,  just 
as  personal  salesrr\anship  produces  business  where  impersonal 
advertisements  fail,  so  the  home  visitor,  usually  a  school  nurse, 
secures  the  correction  of  many  defects  which  are  otherwise  ig- 
nored by  the  parent.  In  this  connection  it  is  worth  while  noting 
that,  without  a  nurse,  the  proportion  of  defects  corrected  usually 
is  from  five  to  thirty  per  cent,  according  to  the  zeal  and  intelli- 
gence of  the  inspector;  while,  with  the  aid  of  a  home  visitor, 
medical  inspection  succeeds  in  the  correction  of  about  sixty  per 
cent,  of  the  defects  found.  It  must  be  acknowledged  that  nurses 
have  been  employed  up  to  the  present  time  only  in  the  poorer 
districts  of  our  cities,  where  docile  foreign  mothers  and  the  nearby 
existence  of  free  medical  dispensaries  have  made  the  work 
productive  of  large  results.    Exactly  what  the  success  of  the  home 

(492) 


The  Physical  Care  of  Children  249 

visitor  would  be  among  American  school  children  of  the  better 
class  cannot  be  determined  in  the  absence  of  trial,  but  naturally 
the  results  obtained  would  be  greater  than  those  obtained  simply 
by  notifications. 

Briefly  in  this  connection  may  be  mentioned  several  aids  to 
the  work  of  medical  inspection,  which  have  developed  as  their 
usefulness  has  become  apparent  in  the  light  of  experience :  Free 
dental  dispensaries,  conducted  by  a  municipality ;  free,  or  almost 
free,  lunches  in  the  schools  of  the  poorer  sections;  the  services 
of  specialists  in  eye,  skin  and  mental  diseases ;  and  the  institution 
of  a  specific  corrective  exercise  by  the  instructors  in  physical  edu- 
cation for  those  children  found  needing  them  by  the  medical 
inspectors.  Realization  by  the  authorities  in  the  school  system 
that  all  children  differ  in  personality  and  capability  has  resulted 
in  the  institution  of  sub-classes  for  the  mentally  deficient,  the 
poorly  nourished,  the  tuberculosis,  the  blind,  the  crippled  and 
the  deaf;  while  the  municipal  government  does  and  has  shown 
its  appreciation  of  the  necessity  of  fresh  air  and  free  outdoor  play 
for  school  children,  by  providing  playgrounds  and  recreation  cen- 
ters, the  latter  often  in  the  school  yards. 

By  the  combined  effect  of  these  agents,  it  is  hoped  that  the 
physical  standard  of  the  race  may  be  appreciably  raised,  and 
the  corresponding  increase  in  average  intelligence  will  result  in 
a  better  standard  of  citizenship. 


(493) 


WHAT  AMERICAN  CITIES  ARE  DOING  FOR  THE 
HEALTH  OF  SCHOOL  CHILDREN 


By  Leonard  P.  Ayres, 

Russell  Sage  Foundation,  New  York. 


/.    Medical  Inspection. 

A  little  more  than  sixteen  years  ago,  in  1894,  and  as  a  result 
of  some  serious  epidemics  among  school  children,  the  city  of  Boston 
divided  its  public  schools  into  fifty  districts  and  appointed  fifty 
school  doctors  to  begin  medical  inspection  in  them.  The  Depart- 
ment of  Child  Hygiene  of  the  Russell  Sage  Foundation  is  now 
making  an  investigation  to  find  out  what  progress  has  been  made  in 
this  field  in  the  sixteen  years  that  have  elapsed  since  this  beginning. 

There  are  in  this  country  some  1,285  cities  having  organized 
systems  of  graded  public  schools  under  superintendents.  The  in-\ 
vestigation  covers  these  cities,  and  up  to  the  present  time  full 
returns  have  been  received  from  758  of  them.  For  purposes  of 
tabulating  results,  the  several  states  of  the  Union  have  been  divided 
into  five  groups,  following  the  order  adopted  by  the  United  States 
census.  These  groups,  with  the  states  comprising  them,  are  as 
follows : 

North  Atlantic  Division. — Maine,  New  Hampshire,  Vermont, 
Massachusetts,  Rhode  Island,  Connecticut,  New  York,  New  Jersey, 
Pennsylvania. 

South  Atlantic  Division. — Delaware,  Maryland,  District  of 
Columbia,  Virginia,  West  Virginia,  North  Carolina,  South  Carolina, 
Georgia,  Florida. 

South  Central  Division. — Kentucky,  Tennessee,  Alabama,  Mis- 
sissippi, Louisiana,  Texas,  Arkansas,  Oklahoma. 

North  Central  Division. — Ohio,  Indiana,  Illinois,  Michigan, 
Wisconsin,  Minnesota,  Iowa,  Missouri,  North  Dakota,  South 
Dakota,  Nebraska,  Kansas. 

Western  Division. — Montana,  Wyoming,  Colorado,  New 
Mexico,  Arizona,  Utah,  Nevada,  Idaho,  Washington,  Oregon,  Cali- 
fornia. 

Forty-five  per  cent  of  the  cities  reporting  have  regularly  organ- 
ized systems  of  medical   inspection  in  their  public  schools.     The 

(404) 


IVhat  American  Cities  are  Doing  for  School  Children        251 

number  of  cities  reporting,  the  number  having  systems  of  medical 
inspection,  and  the  per  cent  having  such  systems  in  each  group  are 
shown  in  the  following  table : 

Cities  Having  Medical  Inspection 

r»-,,:,.;„^  r':*-„„  _~,  ^: Cities  having  Per  cent  having 

Division.  Cit.es  reporting  medical  inspection     medical  inspection 

North  Atlantic 308  182  59 

South  Atlantic 45  .15  38 

South  Central    67  25  37 

North  Central  286  84  29 

Western     52  31  60 

United  States 758  337  45 

The  percentage  figures  in  the  final  column  show  that  medical 
inspection  has  made  the  best  progress  in  the  North  Atlantic  and 
Western  Divisions,  where  about  sixty  per  cent  of  the  cities  have 
taken  up  the  new  work.  It  has  made  substantially  equal  progress 
in  the  two  Southern  Divisions,  where  the  percentages  are  thirty- 
seven  and  thirty-eight,  and  the  poorest  showing  is  made  by  the 
North  Central  Division,  where  only  twenty-nine  per  cent  of  the  cities 
have  medical  inspection  systems. 

There  are  two  standard  types  of  administration,  that  under  the 
board  of  health  and  that  under  the  board  of  education.  In  the 
early  days  of  medical  inspection,  practically  all  the  systems  were 
administered  by  local  boards  of  health,  but  in  recent  years  the  tide 
has  turned  the  other  way.  until  at  the  present  time  about  one- 
quarter  of  the  cities  have  systems  under  their  boards  of  health,  and 
in  the  remaining  three-quarters  the  board  of  education  is  the  con- 
trolling body.  The  facts  for  the  different  divisions  are  shown  in 
tlie  following  table : 
The  Administration  of  Medical  Inspection  Among  337  Cities  Reporting 

-,.   .  .  By  boards  of  By  boards  of 

D»^'s«^"  health  education 

North  Atlantic 49  ^33 

South  Atlantic 5  10 

South  Central 8  17 

North  Central   16  68 

Western  8  23 

United  States 86  251 

The  professional  employees  who  are  administering  these  efforts 

(495) 


252  The  Annals  of  the  American  Academy 

in   behalf  of  the  health   of   school   children   include    1,194   school 
doctors,  371  nurses,  and  48  dentists. 

In  general,  medical  inspection  of  schools  has  two  main  func- 
tions or  divisions.  The  first  is  inspection  for  the  detection  of  com- 
municable disease.  This  relates  primarily  to  the  immediate  protec- 
tion of  the  community,  and  is  in  general  the  first  work  undertaken. 
In  many  states  the  authorities  are  content  with  this  purely  preventive 
work,  and  attempt  nothing  more  elaborate.  The  second  division 
of  the  work  consists  of  physical  examinations  of  children,  which 
aim  to  discover  their  physical  defects  and  look  to  securing  and  main- 
taining the  health  and  vitality  of  the  individual  child.  Among  the 
337  cities  reporting,  301  include  systems  for  the  detection  of  con- 
tagious diseases,  but  only  a  little  more  than  half  of  them  undertake 
physical  examinations.  Moreover,  the  cities  attempting  physical 
examinations  are  mostly  in  the  North  Atlantic  division,  where  the 
work  is  oldest  and  is  most  highly  developed.  In  the  table  which 
follows,  figures  are  presented  showing  the  number  of  cities  in  each 
division  including  inspection  for  the  detection  of  contagious  diseases 
and  physical  examinations  in  their  medical  inspection  systems. 

Inspection  for  the  Detection  of  Contagious  Diseases  and  Examinations 
FOR  THE  Detection  of  Physical  Defects 

■p..   .  .                                                                    Inspection  for  Inspection  for 

uivision                                                         contagious  diseases  physical  defects 

North   Atlantic    173  III 

South  Atlantic 14  6 

South  Central    23  9 

North  Central   67  26 

Western  24  15 

United  States 301  167 

There  is  one  branch  of  medical  inspection  work  which  is  even 
more  universal  than  the  inspection  for  the  detection  of  contagious 
diseases  and  this  is  the  testing  of  pupils  to  discover  defects  of  vision 
and  hearing.  This  testing  has  not  been  included  under  the  general 
heading  of  examinations  for  the  detection  of  contagious  diseases  for 
the  reason  that  it  is  often  carried  on  where  there  is  no  organized 
system  of  medical  inspection  and  the  tests  are  frequently  given  by 
teachers  rather  than  by  doctors  or  oculists.  How  common  these 
tests  are  is  shown  by  the  fact  that  although  only  337  cities  report 
regular  systems  of  medical  inspection.  449  report  that  vision  and 

(496) 


What  American  Cities  are  Doing  for  School  Children       253 

hearing  tests  are  conducted  in  their  schools  by  teachers,  and  in 
addition  there  are  189  cities  where  the  tests  are  conducted  by 
doctors.  The  detailed  facts  as  to  tests  by  doctors  and  teachers  are 
as  follows: 

Vision  and  Hearing  Tests  Conducted  by  Doctors  and  by  Teachers 

Division  Tests  by  doctors  Tests  by  teachers 

North  Atlantic    95  I99 

South  Atlantic 9  15 

South  Central 14  25 

North  Central  54  184 

Western  17  26 

United  States 189  449 

The  fact  has  already  been  mentioned  that  1,194  school  doctors 
are  employed  in  the  work  of  medical  inspection  in  the  cities  report- 
ing. More  than  half  of  these  are  in  the  North  Atlantic  states, 
and  more  than  half  of  the  remainder  in  the  North  Central  states. 
Their  distribution  in  the  several  divisions  is  as  follows: 

Number  of  School  Doctors  Employed  in  Medical  Inspection 

Division  Number  of  doctors 

North  Atlantic 729 

South  Atlantic 45 

South  Central    31 

North  Central  342 

Western  47 

United   States    i,i94 

The  employment  of  school  nurses  in  the  work  of  medical  inspec- 
tion is  a  comparatively  modern  development.  Less  than  a  quarter 
of  the  cities  reporting  medical  inspection  employ  school  nurses,  and 
of  these  more  than  half  are  in  the  North  Atlantic  Division.  The 
total  number  of  cities  employing  nurses  is  seventy-six,  and  the 
total  number  of  nurses  employed  371.  Of  these,  thirty-nine  cities, 
employing  242  nurses  are  in  the  North  Atlantic  Division.  In  the 
South  Atlantic  states,  only  four  cities  employ  school  nurses,  and  the 
total  number  employed  is  only  ten.  The  lowest  record  is  made  by 
the  South  Central  states,  where  two  cities  employ  one  nurse  each. 
In  the  North  Central  states  twenty-one  cities  employ  ninety-six 
nurses,  and  in  the  Western  Division  there  are  ten  cities  with  twenty- 
one  nurses. 

(497) 


254  The  Annals  of  the  American  Academy 

The  school  dentist  is  a  still  more  recent  development  of  medical 
inspection  than  the  school  nurse.  In  the  entire  country  only  forty- 
eight  cities  employ  school  dentists,  of  which  eighteen  are  in  the 
North  Atlantic  Division,  three  in  the  South  Atlantic,  two  in  the 
South  Central,  twenty-one  in  the  North  Central,  and  four  in  the 
Western  Division. 

The  salaries  paid  to  school  doctors  and  school  nurses  vary  from 
nothing  to  nearly  $4,000.  In  many  localities  the  local  medical 
association  conducts  medical  inspection  for  a  year  or  two  without 
cost  to  the  city  in  order  to  demonstrate  its  value.  This  results  in 
the  record  showing  that  in  a  considerable  number  of  the  cities  the 
doctors  receive  no  pay  at  all  for  their  services.  It  may  also  be  a 
factor  in  bringing  about  the  extremely  low  salaries  that  are  received 
by  the  school  doctors  in  many  cities  after  they  are  given  regular 
payment. 

Annual  Salaries  of  Doctors  and  Nurses  in  All  Cities  Reporting 

Number  of  Number  of 

cities  where  cities  where 

doctors  receive  nurses  receive 

salary  indicated  salary  indicated 

No  salary 30                               2 

$1     -100   42                               4 

$101-200  34 

$201-300  32                                2 

$301-400  21 

$401-500  19 

$501-600  14                              IS 

$601-700  I                               13 

$701-800  9                              19 

$801-900  4                              II 

$901-1,000    II 

$1,001-1,500    14                               2 

$1,501-2,500    3 

$3,500-4,000    2 

Fees  according  to  service 16                                 I 

The  same  factors  result  in  similar  conditions  among  school 
nurses.  The  preceding  table  shows  the  number  of  cities  in  which  the 
salaries  of  doctors  and  nurses  fall  within  the  salary  limits  named 
in  each  group.  That  is  to  say  the  first  line  shows  that  there  are 
thirty  cities  in  which  the  doctors  donate  their  services  and  two  in 
which  the  school  nurses  do  the  same  thing.  The  second  line  indi- 
cates that  there  are  forty-two  cities  in  which  the  salaries  paid  to  the 

(498) 


What  American  Cities  are  Doing  for  School  Children       255 

doctors  are  between  $1  and  $100  per  annum  and  four  cities  where 
the  nurses  are  in  receipt  of  similar  salaries. 

The  table  shows  that  there  are  more  cities  paying  their  school 
physicians  at  a  rate  of  between  $1  and  $100  per  year  than  there 
are  paying  salaries  of  any  other  size.  The  average  salary  on  the 
other  hand  is  somewhat  higher  than  this.  If  computed  on  the  basis 
of  the  table  and  without  taking  into  account  the  number  of  doctors 
employed  in  each  individual  city  the  average  salary  would  fall 
within  the  group  receiving  from  $201  to  $300  per  annum.  In  a 
similar  way  the  second  column  of  the  table  shows  that  there  are  more 
cities  paying  their  school  nurses  from  $701  to  $800  per  annum  than 
there  are  paying  any  other  salary.  But  the  average  salary  would 
fall  within  the  group  from  $601  to  $700  per  year. 

It  has  been  stated  that  the  first  system  of  medical  inspection  was 
inaugurated  by  Boston  in  the  year  1894,  and  historically  this  state- 
ment seerns  to  be  correct.  Nevertheless  one  city  claims  to  have 
been  doing  enough  work  for  the  health  of  school  children  to  warrant 
it  in  reporting  that  it  had  a  system  of  medical  inspection  in  the 
year  1890.  Ten  years  later,  in  1900,  eight  cities  had  such  systems, 
and  in  the  five  following  years  the  increase  had  brought  the  total 
number  up  to  forty-four.  The  real  development  of  medical  inspec- 
tion has  come  in  the  past  five  years,  during  which  the  number  has 
increased  from  less  than  fifty  to  more  than  300.  Out  of  the  337 
cities  reporting  systems  of  medical  inspection,  only  312  state  the  year 
in  which  work  was  first  begun.  From  the  records  of  these  cities 
a  table  has  been  compiled  showing  the  total  number  of  cities  having 
medical  inspection  systems  in  each  year  since  the  first  city  began. 
These  facts  follow: 

Number  of  Cities  Having  Systems  of  Medical  Inspection  in  Each  Year 

FROM  1890  TO  1910 

Year  Number  of  cities  Year  Number  cf  cities 

1904    28 


1890  I 

1894  3 

1897  4 

1898  7 

1900  •     8 

1901  14 

1902  20 

1903  22, 


1905  44 

1906  63 

1907  90 

1908  135 

1909  211 

1910  312 


(499) 


256  The  Annals  of  the  American  Academy 

The  detailed  reports  for  the  separate  cities  and  the  tabulations 
bringing  the  facts  together  for  the  individual  states  contain  a  vast 
amount  of  material  of  value  and  interest,  but  of  such  bulk  that  it 
would  be  impossible  to  present  it  here.  The  total  number  of  items 
is  about  25,000.  It  is  our  intention  to  compile  it  in  full  and  present 
it  in  a  final  report  of  this  investigation.  As  showing  the  extremes 
among  the  reports  of  the  different  states,  it  is  interesting  to  note 
that  the  best  record  of  all  is  made  by  the  State  of  New  Jersey,  where 
thirty-four  cities  reported,  and  every  one  of  them  has  an  organized 
system  of  medical  inspection.  Massachusetts  is  a  close  second ; 
among  eighty-six  cities  all  but  two  have  medical  inspection  systems 
and  in  Colorado  among  six  cities  reporting,  there  is  only  one  not 
having  medical  inspection.  The  states  at  the  other  extreme  of  the 
scale  which  report  no  cities  with  medical  inspection  are  Vermont, 
Florida,  Idaho  and  Montana. 

//.    Hygiene  of  the  School  Room 

The  gathering  of  the  salient  facts  regarding  the  present  status 
of  medical  inspection  was  not  the  sole  object  of  the  investigation 
now  under  way.  A  second  and  related  purpose  was  to  discover 
what  the  different  cities  are  doing  in  the  administration  of  the  health 
interests  of  their  school  children  in  such  matters  as  recesses,  the 
cleanliness  of  floors  and  windows,  precautions  as  to  drinking  cups 
and  instruction  in  such  matters  as  the  prevention  of  tuberculosis 
and  the  giving  of  first  aid  in  emergencies. 

It  is  generally  taken  as  a  matter  of  course  that  the  outdoor 
recess  is  part  of  the  regular  program  in  all  elementary  grades,  and 
in  both  sessions  of  the  day  school.  Moreover  such  is  the  case  in 
large  sections  of  the  country,  but  the  data  gathered  show  that  it 
is  far  from  being  true  in  the  North  Atlantic  States,  and  that  in  the 
other  divisions  there  are  cities  where  the  children  arc  not  given 
outdoor  recesses.  The  figures  showing  the  number  of  cities  having 
outdoor  recesses  in  their  elementary  classes,  and  the  per  cent  of 
such  cities,  are  given  in  the  table  on  page  257. 

Another  subject  for  investigation  was  the  extent  to  which  indi- 
vidual drinking  cups  and  sanitary  foiuitains  are  in  use  in  the  dif- 
ferent cities.  As  the  information  was  gathered,  the  city  recorded 
as  having  sanitary  drinking  fountains  or  individual  cups  has  at 
least  made  a  beginning  in  these  directions.    The  figures  given  here 

(500) 


Having  out- 

Per cent  hav- 

door  recess 

jng  recess 

259 

84 

44 

98 

67 

100 

264 

92 

49 

94 

What  American  Cities  are  Doing  for  School  Children       257 

do  not  indicate  what  proportion  of  the  schools  of  each  city  have 
these  appHances.  They  merely  indicate  that  at  least  a  beginning 
has  been  made.  The  figures  show  that  in  twenty-five  per  cent  of 
the  cities  individual  drinking  cups  are  in  use,  and  in  seventy-five 
per  cent  the  schools  have  sanitary  drinking  fountains.  These  figures 
do  not  mean  that  all  cities  are  supplied  with  either  individual  drink- 
ing cups  or  sanitary  fountains,  for  the  data  include  many  duplicates. 
A  considerable  number  of  cities  have  schools  equipped  with  both 
individual  cups  and  sanitary  fountains,  and,  on  the  other  hand,  some 
cities  have  not  introduced  either  the  one  or  the  other. 

Number  and  Per  Cent  of  Cities  Having  Outdoor  Recesses  m  All 
Elementary  Grades 

Cities 
Division  reporting 

North  Atlantic   308 

South  Atlantic  45 

South  Central    67 

North  Central   286 

Western  52 

United   States    758  683  90 

The  group  of  facts  pertaining  to  the  hygiene  of  the  school 
room  was  gathered  from  the  entire  758  cities  from  which  returns 
have  been  received  to  date.  They  show  that  in  considerably  over 
half  of  the  cities  moist  cloths  are  used  for  dusting ;  in  nearly  all  of 
them  dust-absorbing  compounds  are  used  in  sweeping;  and  that 
in  nearly  a  tenth  of  them  the  schools  are  equipped  with  vacuum 
cleaners. 

But  a  slight  knowledge  of  housekeeping  is  necessary  to  make 
one  realize  that  the  appliances  used  for  cleaning  are  not  of  such 
importance  as  the  frequency  with  which  they  are  employed.  Hav- 
ing this  in  mind  we  have  gathered  the  facts  as  to  the  frequency 
with  which  the  school  room  floors  are  washed  and  swept,  and  the 
windows  washed  in  the  public  schools  of  these  758  cities.  The 
facts,  as  reported,  are  shown  in  the  table  on  page  258. 

The  figures  are  illuminating  as  they  are  unique.  Probably  these 
details  of  municipal  housekeeping  have  not  before  been  gathered. 
They  seem  to  indicate  that  the  most  common  practice  sanctions 
the  washing  of  class  room  floors  either  once  a  month,  or  once  in 

(501) 


258 


The  Annals  of  the  American  Academy 


three  months,  although  it  is  by  no  means  rare  to  find  cities  in  which 
they  are  washed  once  in  five  months  or  never  washed  at  all. 

In  the  great  majority  of  the  cities  school  room  floors  are  swept 
once  a  day,  but  nevertheless  there  remains  a  balance  of  nearly  two 
hundred  cities  in  which  they  are  swept  less  frequently.  Six  cities 
report  that  they  are  swept  only  once  a  week;  two  cities  once  a 
month ;  two  cities  that  they  are  swept  only  once  in  five  months. 

More  cities  seem  to  wash  their  class  room  windows  once  in 
three  months  than  on  any  other  regular  schedule.  On  the  other  hand 
one  city  reports  washing  them  once  a  day,  and  five  cities  that  they 
never  wash  them  at  all. 


Number  of  Cities  in  Which  the  School  Room  Floors  are  Washed  and 

Swept  and  the  School  Room  Windows  Washed 

with  Frequencies  Indicated 

Cities  where  floors       Cities  where  floors         Cities  where  win- 

p,                                 are  washed  with  are  swept  with  dows  are  washed 

rrequency                    frequency  frequency  with  frequency 

indicated  indicatea  indicated 

Daily i  574  i 

Once  in  2  days i  49  I 

Once  in  3  days 3  86 

Weekly 36  6  22 

Once  in  2  weeks 27  2  8           . 

Once  in  3  weeks 8  ..  5 

Monthly  135  2  117 

Once  in  2  months 50  i  84 

Once  in  3  months 140  . .  139 

Once  in  5  months 115  2  ill 

Once  a  year 57  . .  31 

As  needed  68  10  139 

Never  44  . .  5 

Not  reporting y^  26  95 

Total 758  758  758 


Adjustable  desks,  which  can  be  fitted  to  the  size  of  the  pupils, 
are  more  common  proportionately  in  the  North  Atlantic  states  than 
elsewhere.  In  the  country,  as  a  whole,  they  are  in  use  in  practically 
half  of  the  cities.  They  are  more  common  in  the  North  than  in 
the  South.  The  fio^iires  showing  the  number  of  cities  where  they  are 
in  use.  and  the  per  cent  which  these  are  of  the  entire  number  report- 
ing, are  as  follows: 

(502) 


What  American  Cities  are  Doing  for  School  Children       259 
Number  of  Cities  Using  Adjustable  Desks  in  Their  Schools 

Number  having  Per  cent  having 

Division  adjustable  adjustable 

desks  desks 

North    Atlantic    213  69 

South  Atlantic 12  ^Jf 

South  Central    18  27 

North  Central  92  32 

Western  23  44 

United  States 358  47 

Just  as  highly  perfected  methods  for  cleaning  are  not  effica- 
cious unless  they  are  frequently  used,  so  adjustable  desks  are  not 
beneficial  unless  they  are  frequently  adjusted  to  the  size  of  the 
children  using  them.  These  358  cities  having  adjustable  desks 
report  that  they  are  adjusted  as  follows: 


Cities  Adjusting  Desks  at  Each  Interval  Named 

T   .         1  Number  of 

Interval  <^ties 

Daily     I 

Once  a  month 3 

Once  in  3  months 14 

Once  in  5  months 12 

Once  a  year 7 

As  needed  283 

Never   i 

Not  reporting ^■^ 

Total 358 

Besides  the  indirect  benefit  and  training  which  the  children 
receive  from  having  their  class  rooms  hygienically  administered 
there  remains  the  question  of  the  direct  instruction  they  receive  in 
theoretical  and  applied  hygiene.  To  discover  something  of  what 
is  being  done  in  this  field  facts  have  been  gathered  showing  the 
number  of  cities  having  regular  courses  for  teaching  the  children 
about  the  effects  of  the  use  of  alcohol  and  tobacco,  for  training 
them  in  the  avoidance  and  cure  of  tuberculosis,  and  in  giving  them 
instruction  about  first  aid  to  the  injured. 

The  figures  show  that  ninety-five  per  cent  of  the  cities  teach 
their  children  the  eflfects  of  alcohol  and  tobacco;  sixty-one  per 
cent  have  special  courses  on  the  prevention  and  cure  of  tubercu- 

(503) 


AND  First 

Aid 

Icohol  and 
tobacco 

Tuberculosis 

First  aid 

293 

203 

i6s 

39 

25 

18 

60 

40 

37 

276 

169 

178 

49 

25 

32 

260  The  Annals  of  the  ximcrkan  Academy 

losis;  and  fifty-seven  per  cent  give  lessons  in  first  aid.  The  figures 
showing  the  number  of  cities  doing  each  kind  of  work  in  each  of 
the  five  divisions,  follow: 

Cities  Giving  Instruction  in  Alcohol  and  Tobacco,  Tuberculosis, 

Division 

North  Atlantic    

South  Atlantic 

South  Central 

North  Central 

Western  

United  States 717  462  430 

The  facts  that  have  been  so  rapidly  reviewed  show  that  com- 
munities over  the  entire  country  are  seeing  the  whole  matter  of 
the  health  of  school  children  in  a  new  light.  Gradually  they  are 
beginning  to  ask,  not  whether  they  can  aflFord  to  take  steps  to  safe- 
guard in  the  schools  the  welfare  of  their  children  but,  whether  they 
can  aflford  not  to  take  such  steps.  The  movement,  as  a  whole,  con- 
stitutes both  a  sign  and  a  result  of  the  gradual  awakening  which 
has  developed  into  a  wave  of  interest  in  matters  pertaining  to  the 
health  of  school  children  that  is  now  sweeping  over  the  civilized 
world. 

We  are  beginning  to  realize  that  the  public  schools  are  a 
public  trust.  When  the  parents  deliver  a  child  to  their  care  they 
have  a  right  to  expect  that  the  child,  under  the  supervision  of  the 
school  authorities,  will  be  safe  from  harm  and  will  at  least  be 
handed  back  to  them  in  as  good  condition  as  he  was  at  first.  Indi- 
vidual efficiency  rests  not  alone  on  education  or  intelligence,  but 
is  equally  dependent  on  physical  health  and  vigor.  Hence,  if  the 
state  may  make  mandatory  training  in  intelligence,  it  may  also 
demand  training  to  secure  physical  soundness  and  capacity.  Much 
time  will  elapse  before  there  will  be  brought  to  bear  in  all  schools 
measures  now  so  successfully  pursued  in  some  for  preserving  and 
developing  the  physical  soundness  of  rising  generations.  Never- 
theless, the  movement  is  so  intimately  related  to  the  future  welfare 
of  our  country  and  is  being  pushed  forward  with  such  great  energy 
and  earnestness  that  it  is  destined  to  be  successful  and  permanent. 

(504) 


THE  ELIMINATION  OF  FEEBLE-MINDEDNESS 


By  Henry  Herbert  Goddard,  Ph.D., 

The  Training  School,  Vineland,  N.  J. 


Feeble-mindedness  may  be  defined  as  a  state  of  mental  defect 
from  birth  or  from  an  early  age  due  to  incomplete  or  abnormal  de- 
velopment, in  consequence  of  which  the  person  afflicted  is  incapable 
of  performing  his  duties  as  a  member  of  society  in  the  position  of 
life  to  which  he  is  born.  There  are  according  to  the  most  careful 
and  reasonable  estimates  in  the  United  States  about  three  hundred 
thousand  persons  who  would  come  under  this  definition.  These  are 
conveniently  divided  into  three  groups:  (a)  lowest,  or  idiots,  (b) 
middle  group,  or  imbeciles,  and  (c)  highest  group,  formerly  called 
the  feeble-minded  in  a  specific  sense,  but  to  whom  we  are  now  giving 
the  name  of  moron. 

The  following  definitions  of  these  groups  were  given  by  the 
Royal  College  of  Physicians  of  London,  and  were  adopted  by  the 
Royal  Commission  on  the  Feeble-Minded  as  a  basis  of  classification. 
The  idiot  is  defined  as  ''a  person  so  deeply  defective  in  mind  from 
birth  or  from  an  early  age  that  he  is  unable  to  guard  himself  against 
common  physical  dangers."  The  imbecile  is  defined  as  "one  who 
by  reason  of  mental  defect  existing  from  birth  or  from  an  early 
age  is  incapable  of  earning  his  own  living,  but  is  capable  of  guarding 
himself  against  common  physical  dangers."  While  the  moron  is 
defined  as  "one  who  is  capable  of  earning  his  living  under  favorable 
circumstances,  but  is  incapable  from  mental  defect  existing  from 
birth  or  from  an  early  age,  (fl)  of  competing  on  equal  terms  with 
his  normal  fellows,  or  (b)  of  managing  himself  and  his  afifairs  with 
ordinary  prudence." 

Why  We  Should  Eliminate  Feeble-Mindedness 

The  part  of  feeble-mindedness  that  comes  under  the  term 
"idiocy"  comprises  a  group  of  helpless  children  who  are  no  comfort 
to  themselves  and  no  comfort  to  their  parents  or  caretakers.  Of 
all  pitiable  humanity  probably  the  idiot  comes  in  for  the  largest  share 
of  sympathy  from  those  who  see  him.     He  is  a  source  of  expense 

(505) 


262  The  Annals  of  the  American  Academy 

and  trouble.  No  matter  how  freely  the  trouble  may  be  met  by  those 
nearest  of  kin,  it  is  nevertheless  true,  that  a  child  so  afflicted  is  a 
constant  source  of  unpleasantness  and  unhappiness  to  all  those  who 
have  to  do  with  him.  Surely  every  one  would  say,  if  it  is  possible  to 
eliminate  this  kind  of  feeble-mindedness  it  must  be  done.  Never- 
theless, as  we  shall  see  later,  this  is  of  all  the  groups  the  least  ob- 
jectionable and  the  least  dangerous. 

The  group  called  "imbeciles"  comprises  those  persons  who  are 
usually  recognized  as  silly,  foolish,  or  stupid.  They  can,  if  wisely 
trained  be  made  to  do  some  work  and  be  a  little  helpful.  But  they 
are  always  a  menace  to  society  because  it  can  never  be  determined 
beforehand  when  any  one  of  them  may  yield  to  any  of  his  natural 
impulses  and  destroy  life  or  property.  Society  must  set  a  large 
army  of  teachers,  trainers,  or  attendants  to  watch  over  and  care 
for  these,  or  be  in  continual  danger  of  injury  or  even  destruction  at 
the  hand  of  this  irresponsible  group.  The  elimination  of  this  grade 
of  feeble-mindedness  would  result  in  an  enormous  improvement 
in  happiness  and  possibilities  of  achievement  in  every  comm.unity. 

The  highest  group,  the  "moron,"  comprises  those  persons  who 
to  the  superficial  view  are  often  considered  normal  but  somewhat 
backward  or  dull.  As  the  definition  tells  us,  there  are  two  charac- 
teristics of  these  people.  The  first  is  that  they  are  unable  to  com- 
pete on  equal  terms  with  their  fellows ;  and,  second,  they  are  unable 
to  manage  their  affairs  with  ordinary  prudence.  The  result  of  the 
second  characteristic  is  that  again  it  requires  a  large  army  of  people 
to  take  care  of  these  morons,  and  to  see  that  their  afifairs  are  man- 
aged with  prudence.  In  the  past  it  has  been  difficult  to  provide  for 
this  class  in  this  way  because  the  ordinary  person,  not  recognizing 
this  as  a  form  of  feeble-mindedness  is  unwilling  to  interfere  in  the 
afifairs  of  such  an  individual  and  manage  them  for  him,  as  ought  to 
be  done.  In  consequence  of  these  two  characteristics  of  the  moron, 
he  becomes  an  enormous  drag  upon  society,  and  the  elimination  of 
this  grade  of  feeble-mindedness  would  be  the  greatest  boon  of  all. 
Being  unable  to  compete  on  equal  terms  with  his  normal  fellows,  he 
is  always  either  an  object  of  charity  or  a  dishonest  person.  Not  being 
able  to  earn  a  living  from  his  own  honest  efforts,  he  either  becomes  a 
beggar  and  pauper,  living  more  or  less  at  public  expense,  unless  in- 
deed, he  has  relatives  who  are  willing  to  supplement  what  little 
he  may  earn  and  so  help  out  his  existence,  or  else  he  turns  to  dis- 

(506) 


The  EiimUiation  of  Feehle-Mindedness  263 

honest  practices  in  order  to  get  that  which  he  needs  for  a  Hving. 
And  this  is  the  most  innocent  form  in  which  his  defect  shows  itself. 
In  other  cases  his  natural  instincts,  however  vile  they  may  be,  ex- 
press themselves  to  the  full  because  he  has  no  power  of  control  over 
them,  and  they  easily  turn  him  to  crime.  He  becomes  a  criminal  of 
the  lowest  sort,  and  in  all  these  ways  he  becomes  a  serious  menace  to 
society,  as  he  logically  must. 

But  this  is  not  only  a  matter  of  logic ;  facts  may  be  produced 
to  show  that  this  is  what  actually  happens.  It  has  been  found  by 
some  studies  not  yet  published  by  the  Galton  Laboratory  in  Eng- 
land that  paupers  are  found  in  the  almshouses  who  are  the  children 
of  paupers  that  were  there  before  them,  and  they  in  turn  were  pre- 
ceded by  their  pauper  parents.  In  all  probability  we  have  here 
only  another  case  of  mental  deficiency.  Every  one  who  has  had  to 
do  with  criminals  in  our  jails  and  prisons  recognizes  that  a  large 
per  cent  of  them  are  mentally  defective,  while  those  who  have 
made  any  observations  at  all  upon  the  prostitutes  recognize  that  here 
also  a  considerable  percentage  are  feeble-minded,  and  have  simply 
fallen  into  this  form  of  life  because  they  could  not  make  a  living  in 
any  honest  way,  and  because  they  easily  became  the  victims  of  others 
who  have  had  designs  upon  them. 

These  are  the  people  who  cannot  be  taught  decent  living,  and 
through  their  ignorance  of  things,  which  they  have  not  the  capacity 
to  learn,  they  spread  disease,  through  their  person  and  their  untidy 
surroundings.  They  are  thus  a  menace  to  public  health  as  well  as  to 
morals. 

Thus  it  is  positively  proved  that  the  elimination  of  this  type  of 
feeble-mindedness  would  save  us  a  large  percentage  of  our  pauper- 
ism, of  our  crime,  and  of  prostitution,  to  say  nothing  of  the  large 
army  of  the  ne'er-do-wells  that  are  known  all  about  us ;  and,  again, 
of  those  persons  who  are  known  to  be  defective,  but  are  cared  for 
in  their  own  families  and  make  no  demands  upon  the  public. 

The  relative  number  of  the  different  types  is  very  uncertain 
because  we  have  had  until  recently  no  accurate  means  of  determin- 
ing the  grade  or  degree  of  defect,  but  it  is  perhaps  not  far  wrong 
if  we  assume  that  we  have  twenty-five  per  cent,  in  the  idiot  grade, 
fifty  per  cent,  in  the  imbecile  grade,  and  twenty-five  per  cent,  in  the 
moron.  If  any  correction  is  to  be  made  to  this  estimate,  it  is  prol> 
able  that  there  are  rather  less  idiots  and  rather  more  morons. 

(507) 


264  The  Annals  of  the  American  Academy 

A  study  recently  made  by  the  Vineland  Laboratory  of  the  men- 
tal development  of  the  children  in  an  entire  school  system  of  2,000 
children  shows  three  per  cent,  of  the  first  five  grades  to  be  feeble- 
minded; fifteen  per  cent,  were  two  and  three  years  backward; 
seventy-eight  per  cent,  were  normal,  and  four  per  cent,  were  super- 
normal. 

Can  We  Eliminate  Feeble-Mindednessf 

We  may  consider  this  question  from  two  standpoints :  first, 
can  we  eliminate  feeble-mindedness  without  eliminating  the  feeble- 
minded; or  in  other  words,  can  a  feeble-minded  person  be  cured? 
Since  Seguin,  very  few  persons  who  have  studied  the  problem  have 
been  willing  to  give  anything  but  a  negative  answer  to  this  question. 
Indeed,  it  is  usually  stated  very  emphatically  that  a  person  once 
feeble-minded  is  feeble-minded  always.  But  if  we  look  at  the  ques- 
tion in  the  broadest  way  we  have  to  confess  that  our  sole  reason 
for  saying  that  these  children  are  incurable  is  that  they  never  have 
been  cured.  It  is  quite  a  diflferent  thing  from  being  able  to  say  with 
authority  that  they  never  can  be  cured. 

In  the  case  of  the  lowest  grade,  it  is  true,  we  have  no  reason 
to  hope  for  anything  else.  While  very  little  anatomical  study  has 
been  made,  what  has  been  made  has  given  rise  to  the  conviction  that 
there  are  deficiencies  in  brain  tissue,  such  that  normal  mentality 
could  not  be  produced  under  any  circumstances.  But  the  same  thing 
cannot  be  said  of  the  higher  grades.  Indeed,  our  ignorance  of  ana- 
tomical conditions  is  so  great  that  no  one  can  say  positively  that  the 
feeble-mindedness  in  some  proportion  of  the  moron  type  is  not  due 
to  conditions  which  might  be  easily  changed  if  we  understood  them. 

Recent  findings  in  the  Vineland  Laboratory  seem  to  indicate 
that  in  some  cases  these  children  may  be  perfectly  normal  to  quite 
a  late  age  of  childhood,  possibly  eight  or  ten  years.  If  this  proves  to 
be  the  case,  then  comes  the  very  insistent  question,  Why  may  we 
not  learn  how  to  so  treat  these  children  in  early  years  as  to  prevent 
the  onset  of  this  condition  later? 

By  the  thyroid  treatment  it  has  been  possible  to  restore  the 
cretin  from  the  imbecile  type  to  perfect  normal  conditions,  both  phys- 
ically and  mentally.  If  such  a  result  is  possible  in  this  particular 
type  may  not  something  else  be  discovered  which  will  work  similar 
results  in  other  types?     The  very  thought  of  the  possibility  of  this 

(508) 


The  Elimination  of  Feeble-Mindedness  265 

suggests  the  enormous  need  of  greater  research  along  these  lines. 
Society  might  spend  millions  in  the  study  of  this  problem,  and  the 
efforts  to  eliminate  feeble-mindedness  in  this  manner.  Even  if  the 
results  were  negative  and  it  were  discovered  that  it  is  impossible  they 
would  be  well  worth  having.  But  until  we  have  studied  the  question 
and  found  out  the  actual  condition,  we  are  groping  blindly  in  the 
dark. 

Should  it  eventually  be  proved  that  our  guesses  are  true  and 
that  feeble-mindedness  is  the  result  of  an  inherited  defect,  that  can 
not  be  changed,  then  our  problem  shifts  to  the  other  side,  and  we 
must  ask  ourselves,  can  we  eliminate  feeble-mindedness  by  eliminat- 
ing the  feeble-minded.  This,  of  course,  must  mean  the  prevention 
of  the  production  of  feeble-minded  persons  and  not  the  destruction 
of  such  persons  after  they  are  born.  For  while  the  thought  does 
rise  in  the  mind  of  most  any  visitor  who  looks  at  a  room  full  of 
idiots,  "Oh,  that  these  persons  might  be  quietly  put  to  sleep  and  put 
out  of  this  wretched  condition,"  yet  when  we  attempt  to  face  such 
a  thing  practically  we  find  that  not  only  our  hearts,  but  our  heads, 
revolt  from  such  a  thought.  Humanity,  because  it  is  humanity,  can 
never  resort  to  such  a  procedure,  and  a  child  once  born  into  the 
world  must  live  its  life  until  it  passes  out  by  natural  means  and 
against  all  the  reasonable  efforts  that  we  can  devise  to  keep  it  alive. 

Turning  our  attention  then  to  the  prevention  of  the  birth  of 
feeble-minded  persons,  we  have  several  lines  to  consider.  In  the 
first  place,  we  have  to  review  the  various  known  causes  of  mental 
defect.  We  have,  first,  two  great  groups,  the  feeble-mindedness  that 
is  hereditary,  and  the  feeble-mindedness  that  is  the  result  of  envi- 
ronment. Under  the  latter  head  we  have  possibly  the  following 
causes :  malnutrition,  epileptic  and  infantile  convulsions,  toxic,  primo- 
geniture, traumatic,  premature  birth,  abnormalities  of  labor,  injuries 
to  the  fetus,  abnormal  conditions  of  the  mother  during  pregnancy — 
mental  and  physical,  the  age  of  the  parents,  consanguinity,  syphilis, 
tuberculosis,  alcoholism,  and  disease  of  the  nervous  system.  It  will 
be  seen  that  we  have  taken  environment  in  the  broadest  sense  to 
include  everything  that  may  cause  mental  defect  which  is  not  true 
heredity.  In  the  other  group  we  have  those  cases  where  the  child 
is  feeble-minded  for  no  other  reason  than  that  the  parent  or  grand- 
parent was  feeble-minded;  in  other  words,  the  case  of  true 
inheritance. 

(509) 


266  The  Annals  of  the  American  Academy 

I  have  also  mentioned  in  the  environment  Hst  several  things  that 
studies  show  are  not  causes.  They  are  included  here  because  they 
are  popularly  thought  to  be  causes.  Consanguinity  is  perhaps  the 
most  striking  illustration  of  this.  Age  of  parents  may  be  another; 
also  primogeniture,  and  premature  birth,  while  other  things  men- 
tioned in  this  list  are  still  either  in  doubt  or  are  known  to  have  a 
very  slight  influence.  But  whether  the  influence  be  slight  or  much 
it  is  evident  that  we  can  if  we  know  enough  change  the  environ- 
ment ;  and  the  conditions  which  often  produce  feeble-mindedness 
may  be  eliminated,  thereby  eliminating  the  mental  defect.  But  all 
these  causes  combined  are  small  compared  to  the  one  cause — 
heredity.  The  vast  majority  of  feeble-minded  persons  are  so  be- 
cause parent  or  grandparent  was  feeble-minded  and  there  is  true 
inheritance. 

The  following  two  charts,  illustrative  of  a  large  number,  show 
what  we  mean:  Chart  I  shows  the  feeble-minded  grandchildren  of  a 
feeble-minded  grandmother.  Chart  II  shows  the  feeble-minded 
children  of  a  feeble-minded  father. 

Often  we  have  charts  upon  which  half  the  persons  represented 
are  feeble-minded.  Can  we  eradicate  feeble-mindedness  in  this 
hereditary  form? 

If  a  farmer  has  a  breed  of  cattle  that  he  no  longer  desires  he 
has  simply  to  cease  breeding  from  this  stock  and  the  race  dies  out. 
We  know  that  many  species  in  nature  have  died  out.  And  so  here, 
if  we  have  in  the  feeble-minded  race  an  undesirable  variant  from  the 
normal,  we  can,  if  we  will,  interfere  and  see  to  it  that  this  race  does 
not  perpetuate  itself.  So  the  answer  to  the  question,  can  we  elimi- 
nate the  feeble-minded,  is  answerable  in  the  affirmative.  It  is  true 
that  a  certain  amount  of  feeble-mindedness  is  accidental,  and  acci- 
dents will  always  occur,  so  that  we  may  not  look  forward  to  a  time 
when  there  will  not  be  a  certain  number  of  feeble-minded  persons, 
but  they  will  be  in  such  a  small  proportion  as  to  be  practically  a 
negligible  quantity. 

How  Shall  We  Eliminate  the  Feehle-Minded? 

As  already  implied,  the  only  way  to  eliminate  the  group  of  feeble- 
minded due  to  environmental  conditions  is  to  change  the  environ- 
ment. If  feeble-mindedness  is  sometimes  due  to  abnormal  conditions 
of  the  mother  during  pregnancy,  we  must  study  the  problem  and 

(510) 


The  Elimination  of  Feeble-Mindedness  267 

understand  the  situation  at  that  time,  so  that  abnormal  conditions 
may  not  exist.  If  epileptic  convulsions  produce  feeble-mindedness 
we  must  learn  to  control  epilepsy,  and  so  on  through  the  list.  All 
this  again  implies  that  we  need  an  enormous  amount  of  study  to 
manage  this  problem,  for  as  yet  we  are  absolutely  ignorant  on  nearly 
all  of  these  points,  but  the  possibilities  of  eliminating  this  group  of 


(2)-'(^|n][J3|n]0(n) 


B-T-^i] 


>&-j-(§ 


Chart  I. 


Q-HS) 


ift^ 


b-  (!)&-T-<S)|N]I^(^(N) 


T — r — I 

A      *      * 

ikr.    mr.     w. 


Chart  II. 

Key  to  Charts. 
Square  indicates  male.     Circle  indicates  female.      A,  alcoholic  (habitual 
drunkard).    F,  feeble-minded;  N,  normal;  T,  tuberculous;  small  black  circle 
indicates   miscarriage;   b=born;   d=:died;   inf.=:infancy ;   illeg.=illegitimate ; 
hand  shows  which  child  is  in  the  institution  for  the  feeble-minded. 

the  feeble-minded  is  not  to  be  denied,  and  the  method  is  plain  when 
once  we  have  learned  the  facts. 

All  this  sort  of  feeble-mindedness  ought  to  be  eliminated,  and 
some  day  will  be,  but  on  tlie  other  hand  this  is  actually  only  a  small 
percentage    of    feeble-mindedness,   as    shown   above.     The    feeble- 

(511) 


268  The  Annals  of  the  American  Academy 

mindedness  of  the  greatest  group  is  hereditary,  and  the  cause  of  such 
feeble-niindedness  is  the  feeble-minded  parent  or  grandparent,  and 
our  problem  here  takes  another  turn. 

As  we  face  the  question,  "can  we  prevent  children  being  born 
of  persons  who  are  feeble  minded  ?"  there  are  two  possible  methods. 
The  first  would  be  to  keep  the  sexes  apart;  and  the  second  to  ren- 
der them  incapable  of  reproduction. 

The  first  of  these  is  discussed  usually  under  the  head  of  per- 
manent custodial  care.  This  means  that  society  must  set  to  work 
to  discover  all  of  these  feeble-minded  persons,  and  as  rapidly  as 
possible  segregate  them  in  colonies  where  the  sexes  are  kept  abso- 
lutely apart  so  that  every  feeble-minded  male  and  every  feeble- 
minded female  is  compelled  to  live  his  or  her  life  in  conditions  of 
absolute  sexual  seclusion.  If  this  were  done,  we  would  have  in  a 
single  generation  all  of  the  hereditary  cases  taken  care  of  except 
those  that  arise  sporadically  from  the  free  variation  in  the  stock,  and 
this  would  be  comparatively  small. 

Every  one  admits  that  permanent  custodial  care  is  the  ideal 
solution  of  the  problem,  both  from  the  standpoint  of  eflfectiveness 
and  from  the  standpoint  of  the  humanity  of  the  case.  The  great 
objection  or  difficulty  that  arises  in  connection  with  this,  and  is 
usually  considered  insurmountable,  includes  the  item  of  expense  in- 
volved, and,  second,  the  difficulty  to  getting  all  of  these  people  into 
a  colony  and  under  the  control  of  those  who  have  sufficient  intelli- 
gence. 

The  first  of  these  arguments  is  fallacious.  The  cost  of  such  a 
procedure  would  be  large,  but  it  would  not  be  as  large  as  the  present 
cost  to  society  for  the  care  of  these  same  persons,  to  say  nothing  of 
their  progeny  in  future  generations.  Colonies  for  these  feeble- 
minded would  to  a  large  extent  take  the  place  of  prisons  and  alms- 
houses, with  the  advantage  that  the  persons  in  these  colonies  could 
be  trained  to  more  or  less  useful  work  under  the  supervision  of  ex- 
perts, whereas  the  inmates  of  our  present  institutions  for  the  poor 
and  the  criminals  are  practically  of  no  use  to  society. 

One  must  also  refer  to  the  sentimental  reason  that  is  often  met 
with  that  it  is  cruel,  or  at  least  unpleasant,  to  think  of  placing  these 
children  in  institutions.  To  this  it  must  be  replied  there  are  insti- 
tutions and  institutions.  Any  one  who  cares  to  investigate  the  mat- 
ter may  discover  for  himself  that  it  is  possible  to  have  institutions 

(512) 


The  Elimmation  of  Feeble-Mindedness  269 

for  the  feeble-minded  that  are  the  happiest  places  in  the  world. 
It  is  possible  to  help  these  people  to  live  a  life  of  complete  happi- 
ness in  proportion  to  their  mental  attainments.  .And  one  cannot 
visit  our  best  managed  institutions  without  going  away  with  the  firm 
conviction  that  it  is  possible  to  colonize  all  of  our  feeble-minded  per- 
sons under  conditions  in  which  they  would  be  perfectly  happy. 
Thus  any  objections  that  seem  to  occur  from  the  feeling  that  it  is 
treating  them  badly  are  at  once  eradicated.  Such  ideal  institutions 
would  also  very  largely  eliminate  the  difficulty  of  inducing  parents 
to  give  their  consent  to  the  transfer  of  their  defective  child  to  an 
institution.  However,  the  success  of  such  a  plan  is  not  dependent 
upon  the  consent  of  the  parents.  Even  though  society  finds  itself 
unwilling  forcibly  to  deprive  the  parents  of  their  feeble-minded 
child,  there  is  still  a  possibility.  If  parents  are  unwilling  for  their 
child  to  be  transferred  to  such  a  colony,  the  child  may  be  trained  in 
the  public  school  by  methods  that  are  suited  to  his  mental  condi- 
tion. He  may  be  guarded  by  his  teachers  and  the  probation  officers 
or  some  person  similar  who  keeps  his  eye  upon  such  a  child  while 
he  is  at  home.  After  he  has  left  school,  if  he  leaves  it,  and  upon  the 
slightest  indication  that  he  is  going  wrong,  is  thinking  of  marrying, 
or  is  in  danger  of  becoming  a  parent  out  of  matrimony,  the  State  may 
then  interfere,  and  take  the  child  to  the  colony  home.  Such  a  pro- 
cedure may  be  managed  in  such  a  way  as  not  to  offend  our  most 
sensitive  feelings  for  justice  to  the  defective. 

This  is  not  the  place  to  go  further  into  details,  and  show  how 
such  a  plan  may  be  worked  out  with  entire  success  and  at  a  cost 
that  is  well  within  the  means  of  any  Commonwealth,  and  that  it 
would  be  cheaper  in  money,  more  economical  in  social  life,  and  of 
immense  value  morally.  Time  does  not  permit  me  to  even  extend 
the  argument,  and  show  that  this  colony  idea  is  the  ideal  one  not 
only  from  this  standpoint  of  the  reproduction  of  the  species,  but 
also  from  that  of  the  welfare  of  the  person  and  of  society. 

As  was  said  earlier  in  this  paper,  these  persons  are  all  and 
always  a  menace  to  society.  Aside  from  the  tremendous  menace  of 
procreating  their  kind,  it  can  never  be  predicted  when  one  of  them 
may  commit  crime  or  do  some  action  innocent  to  him  because  of 
his  irresponsibility,  but  which  results  in  loss  of  property  or  life. 
All  of  these  things  make  it  of  the  utmost  desirability  that  these 
children  be  segregated  from  normal  society,  and  be  placed  in  an 

(513) 


270  The  Annals  of  the  American  Academy 

environment  that  not  only  makes  them  happy,  but  makes  them  safe 
from  their  own  defect,  and  makes  other  persons  safe. 

There  is  left  for  consideration  treatment  for  rendering  all  fee- 
ble-minded persons  incapable  of  perpetuating  the  species — what  is 
spoken  of  as  sterilization,  asexualization,  or  unsexing.  Some  method 
for  this  must  undoubtedly  be  considered  and  practiced  to  a  greater 
or  less  extent,  but  it  must  be  remembered  that  it  is  a  makeshift. 
Such  a  procedure  is  very  far  from  being  an  ideal  solution  of  the 
difficulty.  For  reasons  already  mentioned  these  persons  should  be 
segregated  from  normal  people,  and  if  they  are  to  be  segregated 
and  colonized  in  a  place  where  they  can  be  cared  for,  and  trained 
and  made  happy,  any  other  method  is  unnecessary,  the  problem  is 
solved  without  it.  However,  it  is  possible  that  conditions  have  be- 
come so  bad  that  we  must  seize  upon  everything  that  offers  hope  of 
relief.  We  have  taken  such  good  care  of  these  people  for  so  many 
years,  have  allowed  our  humanity  to  get  so  far  ahead  of  our  judg- 
ment and  reason  that  we  have  turned  loose  in  the  community  a  large 
body  of  strong  men  and  women,  well  developed  physically,  but  who 
have  this  hereditary  taint  of  feeble-mindedness.  As  a  result,  feeble- 
minded children  are  being  born  at  such  a  rate  that  the  mere  mechani- 
cal problem  of  constructing  buildings  fast  enough  to  take  care  of 
them  is  serious,  so  serious  that  we  must  resort  to  some  method  as 
a  make-shift  to  help  us  out  of  the  difficulty,  and  get  us  on  our  feet 
and  place  us  where  we  can  control  the  situation.  There  is  no  ques- 
tion that  there  should  be  a  carefully  worded  sterilization  law  upon 
the  statute  book  of  every  State,  and  that  the  practice  should  be  car- 
ried on  judiciously  and  carefully,  but  persistently  all  over  our  coun- 
try, in  order,  as  we  have  already  said,  that  we  may  thus  help  to  get 
control  of  the  situation. 

Two  States  have  already  passed  such  laws.  Several  other 
States  have  introduced  such  bills,  but  they  have  usually  failed  by  a 
small  margin  to  become  law. 

When  we  come  to  practicing  some  method  of  sterilization  we 
are  again  brought  face  to  face  with  our  ignorance  of  methods  and 
results.  We  have  first,  of  course,  the  old  and  time-honored  method 
of  castrating  the  males  and  ovariotomy  for  the  females.  This  is  an 
efficient  method,  and  as  far  as  males  are  concerned,  entirely  safe. 
The  only  objection  to  it  seems  to  be  a  sentimental  one.  Just  what 
are  the  consequences,  the  metabolic  changes  in  the  individual  as  a  re- 

(514) 


The  Elimination  of  Fccble-Mindedness  271 

suit  of  this  operation,  is  not  known  with  any  high  degree  of  scientific 
accuracy.  Nevertheless,  there  are  no  indications  that  there  are  any 
serious  consequences.  The  practice  would  accomplish  great  good 
in  this  line. 

It  must  be  admitted,  however,  that  the  operation  on  the  female 
is  a  somewhat  more  serious  one,  and  can  hardly  be  practiced  on  any 
large  scale  without  some  danger  of  fatalities  in  a  small  percentage 
of  the  cases.  Perhaps  this  is  not  greater  than  occurs  in  such  opera- 
tions as  appendicitis  to  which  normal  people  submit  daily. 

Recently  a  new  method  has  come  into  the  field  which  has  a  few 
very  ardent  advocates,  particularly  as  far  as  the  male  is  concerned. 
The  operation  is  known  as  vasectomy.  It  is  very  simple,  and  may  be 
performed  in  a  few  minutes  in  the  physician's  office,  and  with  no 
other  eflfect  on  the  individual  or  his  activities  than  the  absolute  pre- 
vention of  procreation.  It  is  even  claimed  that  the  result  of  this  is  a 
decided  tonic  effect  upon  the  individual. 

The  analogous  operation  upon  the  female,  that  of  tying  the 
fallopian  tubes,  is  more  difficult  than  the  operation  on  the  males,  and 
as  yet  no  method  of  performing  it  has  been  discovered  that  avoids 
abdominal  section  with  its  concurrent  dangers. 

Biologists  hold  out  some  slight  hope  that  methods  of  steriliza- 
tion by  X-rays  may  yet  be  discovered  and  become  practical.  How- 
ever, that  is  still  so  far  in  the  future  that  it  is  not  worth  the  space 
to  discuss  it  here. 

It  is  noteworthy  in  all  these  methods  that  any  operation  is  much 
more  difficult  on  the  female  than  on  the  male.  This  is  a  crucial 
point,  because  even  if  we  are  content  with  a  partial  result,  the  ster- 
ilization of  the  feeble-minded  males  does  not  begin  to  halve  the 
difficulty.  Experience  shows  that  there  are  many  more  normal  men 
who  will  marrry  or  live  out  of  wedlock  with  feeble-minded  women 
than  vice  versa,  and  consequently,  unless  something  can  be  done  to 
sterilize  the  female,  our  problem  of  eliminating  feeble-mindedness 
by  this  method  is  not  halved. 

Here  again  we  are  faced  by  so  much  ignorance  on  this  matter 
that  it  is  difficult  to  speak  with  any  assurance.  There  is  an  impera- 
tive need  for  careful  study  and  investigation  of  all  of  these  problems. 
Many  of  them  would  yield  to  a  small  outlay  of  time  and  money,  and 
the  answers  would  be  clear  and  assuring;  others  of  them  are  much 
more  difficult,  will  require  longer  and  more  careful  investigation. 

(515) 


272  The  Annals  of  the  American  Academy 

But  in  these  days  of  scientific  advancement  it  is  unwise  for  us  to 
assume  that  any  of  these  are  insolvable.  The  only  wise  and  ra- 
tional method  is  for  us  to  proceed  as  rapidly  as  posssible  to  study 
these  conditions,  and  get  at  fundamental  facts  upon  which  we  can 
base  our  practices. 

I  have  tried  to  show  in  this  paper  as  briefly  and  concisely  as 
possible  the  enormous  prevalance  of  feeble-mindedness ;  (i)  what 
feeble-mindedness  is,  (2)  why  it  ought  to  be  eliminated,  (3)  that 
it  can  be  eliminated,  and  (4)  how  it  can  be  eliminated.  I  have  also 
not  avoided  the  necessisty  of  showing  that  along  many  of  these 
lines  we  still  need  much  more  data.  There  is  absolute  necessity 
for  our  studying  the  problem,  and  finding  out  the  facts  upon  which 
our  solution  must  depend  and  upon  which  we  must  act. 

In  conclusion,  let  me  say  that  the  work  has  been  begim,  and  it  is 
eminently  fitting  and  encouraging  that  the  American  Academy  of 
Political  and  Social  Science  has  and  should  take  up  this  problem, 
and  carry  it  through.  Society  is  ready  for  it,  we  are  beginning  to 
recognize  the  truth  of  the  various  things  presented  in  this  paper,  and 
I  believe  that  it  only  needs  some  person  or  persons,  or  organization 
to  take  up  the  matter,  act  as  leader  and  guide  and  director  in  this 
new  social  movement  in  order  to  carry  out  a  reform  here  which  has 
untold  value  for  the  benefit  of  our  present  society  and  the  humanity 
of  the  future. 


(S16) 


PREVENTION  OF   INFANTILE   BLINDNESS 


By  Charles  F.  F.  Campbell, 

General  Secretary  Pennsylvania  Association  for  the  Blind;  Editor  "Outlook 

for  the  Blind,"  Pittsburg,  Pa. 


One  hundred  thousand  ^  blind  distributed  over  our  great  country 
approximately  one  to  one  thousand — does  not  impress  the  general 
observer  as  an  appalling  condition,  but  if  all  these  could  pass  in 
review,  no  doubt  the  gravity  of  the  situation  would  be  more  striking. 
If  we  could  assemble  even  the  percentage  counted  by  reliable  investi- 
gators as  blind  from  preventable  causes  (accident,  disease,  etc.) — 
some  forty  thousand  in  number — they  would  make  a  formidable 
assemblage,  and  present  a  never-to-be-forgotten  example  of  the  re- 
sults of  ignorance  and  neglect. 

Confining  our  inquiries  to  ophthalmia  neonatorum,  "the  puru- 
lent sore  eyes  of  new-born  babies,"  we  find  that  to  this  is  attributable 
from  one-tenth  to  one-eighth  of  all  blindness  from  all  causes.  Ten 
thousand  persons  are  blind  from  this  one  preventable  disease  alone. 

Private  charity  is  erecting  nurseries  for  the  care  of  blind  infants, 
50  per  cent,  of  whom  are  sightless  because  of  the  ravages  of  this 
disease.  One-fourth  to  one-third  of  all  the  children  in  our  great 
public  and  private  institutions  maintained  for  the  special  education 
of  blind  youth  are  there  as  a  result  of  this  same  disease.  The 
public  is  further  taxed  to  maintain  the  burden  of  the  support  of 
these  blind  children  when  they  reach  adult  life,  and  in  some  instances 
pensions  are  granted. 

The  blind  themselves  are  making  a  most  courageous  struggle 
for  self-support  in  the  face  of  an  inexpressibly  heavy  handicap.  The 
deprivations  of  the  loss  of  sight  to  the  blind  cannot  be  estimated. 
"What  blindness  means  to  an  intelligent,  capable  man  or  woman,"  to 
quote  the  words  of  a  blind  man  who  has,  in  the  face  of  heavy  odds, 

» It  is  pretty  generally  conceded  that  there  are  100,000  blind  in  the 
United  States.  The  absence  of  any  authoritative  definition  of  blindness  ac- 
counts for  the  lack  of  agreement  between  the  Federal  and  State  Censuses 
and  for  the  discrepancy  in  figures  quoted  by  various  writers.  Those  inter- 
ested in  this  phase  of  the  subject  should  study  the  definition  and  classifica- 
tion of  blindness  under  the  three  captions:  (1)  Total  or  absolute  blindness; 
(2)  relative  blindness;  (3)  practical  blindness  as  worked  out  by  Dr.  Lewis 
Striker,  of  Cincinnati. 

'  (517) 


274  The  Annals  of  the  American  Academy 

taken  his  place  in  the  world  with  signal  success,  "is  something  which 
only  the  Lord  and  the  devil  and  those  who  endure  it  know  anything 
about;  in  their  blackest  nightmares,  those  with  sight  cannot  even 
faintly  imagine  it,  and  unemployed  blindness  is  as  much  worse,  as 
despair  is  worse  than  hope."  The  cost  to  the  State  of  maintaining 
a  blind  person  throughout  the  duration  of  his  life  is,  owing  to  in- 
complete data,  difficult  to  compute,  but  approximates  roughly 
$10,000.  Of  the  ten  thousand  blind  from  ophthalmia  neonatorum,  all 
are  probably  dependent  through  childhood  and  youth ;  some  pass 
directly  from  the  school  to  a  home,  and  are  thus  supported  by  private 
or  public  funds  through  their  entire  lives;  others  become  self-sup- 
porting, and  some  partially  so,  through  adult  life.  Again,  others, 
after  leaving  the  school,  maintain  themselves  during  the  so-called 
working  period,  but  have  not  been  able  to  provide  for  old  age,  and 
again  fall  back  upon  state  or  other  charitable  aid.  The  expense  is 
so  distributed,  and  the  appeal  to  the  sympathies  of  legislators  and 
philanthropists  to  "pity  the  poor  blind"  so  compelling,  that  the  aggre- 
gate amount  expended  is  rarely  considered. 

For  the  education  and  maintenance  of  the  victims  of  ophthalmia 
neonatorum  attending  the  state  schools  for  the  blind  in  Massachu- 
setts, New  York,  Ohio  and  Pennsylvania,  the  annual  expenditure  of 
public  funds  in  excess  of  the  cost  of  educating  the  same  number  of 
seeing  children  in  the  public  schools  is  approximately  $110,000.  If 
all  the  figures  were  available,  the  total  annual  excess  cost  in  these 
four  States  for  the  education  and  maintenance  of  children,  blind 
from  this  one  preventable  cause,  would  not  fall  far  short  of  $150,000. 
Less  than  one-tenth  of  this  amount  would  amply  provide  for  the  free 
distribution  of  a  prophylactic  against  ophthalmia  neonatorum,  basing 
the  estimate  on  present  expenditures  in  States  where  such  distribu- 
tion is  in  force.^  But  it  must  be  remembered  that  if  we  had  the 
figures  showing  the  expense  for  the  maintenance  of  the  adults  who 
were  blinded  in  babyhood  from  ophthalmia  neonatorum,  $150,000 
would  not  begin  to  cover  the  annual  cost  of  the  needlessly  blind  in 
these  four  States  alone.  A  very  large  majority  of  the  ten  thousand 
blinded  from  this  cause  are  now  beyond  school  age. 

The  ignorant  idea  of  disease  as  representing  the  chastening 
dispensation  of  Providence,  and  as  such  to  be  meekly  borne,  is 
happily  being  dispelled;  although  we  are  brought  face  to  face  with 

-  In  the  states  in  which  such  provision  exists  New  York  estimates  the 
cost  at  15000,  Massachusetts  at  $2500,  Rhode  Island  $300  to  $400,  Ohio  $1200. 

(518) 


Prevention  of  Infantile  Blindness  275 

such  evidence  to  the  contrary,  as  in  the  case  of  three  children  by  the 
same  parents  blinded  from  ophthalmia  neonatorum,  whose  mother 
accepted  the  repeated  afflictions  as  "the  will  of  God,"  still,  the  in- 
alienable right  of  every  child  to  a  fair  start  in  the  race  of  life  is 
slowly  gaining  recognition. 

It  is  necessary  to  face  the  facts ;  to  make  known  the  true  cause 
of  this  disease,  ophthalmia  neonatorum;  and  arouse  parents  and 
those  caring  for  infants  to  a  realization  of  its  perils,  if  we  are  to 
secure  prompt  and  expert  treatment  for  those  afflicted — if  we  would 
give  even  a  fighting  chance  to  the  one  to  two  per  cent,  of  live  births 
afflicted  with  ophthalmia  neonatorum. 

It  is  not  the  purpose  of  this  paper,  however,  to  attempt  a  scien-r 
tific  treatise  on  ophthalmia  neonatorum,  or  on  the  technique  of  its 
treatment  or  prevention,  but,  rather,  to  call  attention  to  the  prevalence 
of  the  disease,  the  Heedlessness  of  its  cruel  blight  on  innocent  lives, 
and  the  measures  that  are  being  taken  to  check  its  pitiful  havoc  in 
the  United  States.^ 

A  brief  paper  which  admirably  summarizes  the  historical  and 
medical  aspects  of  this  subject,  and  from  which  we  have  quoted 
freely,  was  read  by  George  F.  Keiper,  A.  M.,  M.  D.,  before  the 
Indiana  State  Medical  Association,  September  28,  1910.  As  Doctor 
Keiper  remarks,  "ophthalmia  neonatorum  is  as  old  as  medicine," 
although  it  was  a  long  time  before  the  true  cause  of  the  disease  was 
discovered,  but,  now  that  certain  facts  are  established  beyond  dis- 
pute, "the  problem  of  prevention,"  as  Helen  Keller  says,  "should  be 
dealt  with  frankly.  The  facts  are  not  agreeable  reading,  often 
they  are  revolting." 

While  other  bacteria  may  be  the  cause  of  the  disease,  infantile 
ophthalmia  results,  in  most  cases,  from  gonorrhoeal  *  infection,  usually 
innocently  acquired,  the  destructive  germs  in  the  leucorrheal  dis- 
charge of  the  mother  getting  in  the  eyes  of  the  child,  with  few 
exceptions,  during  or  shortly  after  birth, 

'A  bibliography  of  over  300  articles  and  books  upon  this  subject  is  in 
course  of  preparation  by  the  Pittsburg  Carnegie  Library,  and  will  be  in- 
valuable for  students  of  this  subject.  For  a  study  of  the  movement  in  the 
United  States  the  reader  is  especially  referred  to  the  writings  of  Dr.  Lucien 
Howe,  the  pioneer  in  securing  legislation  for  the  prevention  of  ophthalmia 
neonatorum  in  this  country,  and  to  those  of  Dr.  F.  Park  Lewis,  who  is  the 
inspiration  of  the  present  agitation. 

*  The  most  conservative  autliorities  state  that  tlie  gonococcus  is  re- 
sponsible for  two-thirds  of  all  cases  of  oplithalmia  neonatorum.  Other 
investigators  place  the  percentage  much   higher. 

(519) 


2/6  The  Annals  of  the  American  Academy 

It  is  an  infectious,  contagious  disease,  accompanied  with  the 
secretion  of  pus  from  between  the  eyeHds,  manifesting  itself  usually 
from  a  few  hours  to  a  few  days  after  the  birth  of  the  child,  and,  wheft 
left  untreated,  results  in  great  damage  to,  if  not  destruction  of,  the 
child's  eyesight. 

Ten  thousand  blind  because  of  this  disease !  ^  But  the  move- 
ment to  eradicate  this-  evil  is  a  campaign  of  hope — for  the  cases 
that  do  not  respond  to  proper  treatment  are  so  rare  as  to  be  left  out 
of  the  reckoning,  and  99^/2  times  out  of  100  the  infection  is 
preventable. 

The  two  factors  in  the  treatment  of  this  disease — cleanliness 
and  the  destruction  of  the  fatal  germs  and  resultant  inflammation — 
require  the  most  skillful,  persistent  nursing  and  expert  medical 
attention. 

The  correct  use  of  the  right  prophylactic,  one  of  the  silver  salts, 
can  only  be  intrusted  to  an  expert.  But,  better  than  treatment, 
with  its  uncertainties,  is  prevention.  The  writings  of  Benjamin 
Gibson,  of  Edinburgh,  produced  in  1807,  sound  as  if  written  to- 
day, for  he  says:  "(i)  Remove  the  disease,  if  possible,  in  the 
mother  during  pregnancy;  (2)  if  that  cannot  be  accomplished,  re- 
move artificially  as  much  of  the  discharge  as  possible  from  the 
vagina  at  the  time  of  delivery;  (3)  at  all  events,  pay  particular 
attention  to  the  eyes  of  the  child  by  washing  them  immediately  after 
delivery  with  a  liquid  calculated  to  remove  the  offending  matter 
or  to  prevent  its  noxious  action."  This  was  written  long  before  it 
was  known  that  the  gonococcus  or  any  other  germ  was  the  cause 
of  the  disease.  But,  unfortunately,  the  books  on  medicine  gen- 
erally made  little  or  no  mention  of  ophthalmia  neonatorum  nor  its 
dangers.  In  1874,  or  thereabouts,  various  forms  of  disinfectants 
are  known  to  have  been  used  as  preventives.  In  1879  Neisser  dis- 
covered gonococcus  in  the  secretions  of  the  eyes  of  children  aflfected 
with  ophthalmia,  but  it  was  left  to  Prof.  Carl  Crede,  director  of 
the  Maternity  Hospital,  University  of  Leipsic,  during  the  years  188D- 
1882,  to  systematize  a  means  of  preventing  the  dreaded  disease,  and 
thus  to  confer  upon  succeeding  generations  an  everlasting  benefit. 

'  For  "histories"  of  cases  pathetic  in  tlie  extreme,  tragic  in  number,  see 
"Needlessly  Blind  for  Life,"  Bulletin  No.  1,  Massachusetts  Commission  for 
the  Blind,  and  Reports  of  Social  Service  VV^ork  at  Massachusetts  Charitable 
Eye  and  Ear  Infirmary,  Boston,  Mass. 

(520) 


Prevention  of  Infantile  Blindness  277 

The  method,  as  described  in  his  own  words,  follows:  "The  eyelids 
were  gently  separated  by  an  assistant,  and  by  means  of  a  glass  rod 
a  single  drop  of  the  solution  was  placed  in  each  eye.  For  twenty- 
four  hours  after  the  application  the  eyes  were  cooled  by  means  of 
a  linen  fold,  soaked  in  salicylic  acid  (2:  100)  laid  over  them."  The 
percentage  of  babies  contracting  the  disease  rapidly  fell  when  the 
Crede  formula  was  adopted.® 

The  method  now  used  consists  in  simply  applying  a  i-per-cent. 
solution  of  the  nitrate  of  silver,  one  application  dropped  in  each 
eye,  and  nothing  else  afterward.  Doctor  Howe  says :  "As  this 
solution  of  silver  removes  the  superficial  layer  of  epithelial  cells,  it 
probably  destroys,  at  the  same  time,  any  germs  which  may  be  in 
them.  Whatever  theory  there  may  be  as  to  how  the  nitrate  of  silver 
acts,  there  is,  fortunately,  no  question  as  to  the  practical  results. 
This  has  been  determined  by  exactly  recorded  cases,  which  can  be 
counted  by  the  thousands ;  not  observed  by  one  practitioner,  but  by 
many ;  and  especially  we  have  lists  showing  the  effect  of  treatment 
without  this  method,  as  well  as  with  it." 

In  1887  Dr.  Lucien  Howe,  of  Buffalo,  N.  Y.,  chairman  of  the 
Committee  on  Ophthalmia  Neonatorum,  of  the  American  Ophthal- 
mological  Society,  presented  to  that  body,  and  to  the  New  York 
State  Medical  Society,  a  masterly  array  of  facts  concerning  the 
prevalence  of  ophthalmia  neonatorum  and  the  means  adopted  for 
its  regulation  in  European  countries  together  with  what  statistics 
were  available  in  the  United  States.  The  conclusions  drawn  from 
his  examination  of  the  pupils  in  the  New  York  State  School  at 
Batavia  were  especially  pertinent.  Doctor  Howe  did  not  succeed 
in  legislating  for  compulsory  prophylaxis,  but,  as  a  consequence  of 
his  earnest  work,  the  New  York  Legislature,  in  1890,  enacted  a 
measure  (amended  in  1892),  requiring  that  the  birth  infection  of  the 
eyes  of  infants  be  reported  to  boards  of  health.'^ 

•We  are  told  that  in  1874  there  were  in  his  hospital  323  births,  with 
forty-five  cases  of  ophthalmia  neonatorum — i.  e.,  13.6  per  cent.;  and  in  1882, 
with  260  cases  in  which  tlie  method  was  used,  but  one  case  developed — 
i.  e.,  0.5  per  cent.  From  1880  to  1883  the  percentage  ranged  from  .49  per 
cent,  to  zero.  In  three  years  1160  children  were  born  alive  and  but  one, 
or  at  most,  two  cases  showed  the  disease.  Lucien  Howe  ("New  York  State 
Journal  of  Medicine,"  1906)  collected  statistics  of  1776  cases  having  no  pro- 
phylactic treatment  and  9.2  per  cent,  developed  the  disease,  and  of  24,724 
treated  by  the  CredS  method  only  .65  per  cent,  developed  the  disease. 

^  New  York  "Howe"  Law: 

1.  New  York  State  Midwife  Law  (extract  from  Penal  Code),  Chapter 
J25,  Laws  of  1892. 

(521) 


278  The  Annals  of  the  American  Academy 

This  bill  soon  became  known  as  the  Howe  law  and  was 
copied  by  sixteen  other  States.  Legislation  so  fundamental  in  its 
requirements,  and  marking  the  first  step  in  concerted  action  looking 
toward  the  prevention  of  blindness  in  the  United  States,  was 
accorded  hearty  indorsement  by  the  ophthalmologists,  but  was  over- 
looked or  soon  forgotten  by  the  general  practitioner.  While  our 
ablest  ophthalmologists  are  the  first  to  deplore  the  fact  that  "we 
have  no  standard  by  which  may  be  determined  the  qualifications  of 
a  physician  who  undertakes  such  expert  and  delicate  work,  and 
work  requiring  such  precise  and  technical  knowledge  as  ophthal- 
mology," it  is  to  these  men  that  we  owe  the  inception  of  the  cam- 
paign for  prevention.  Professional  etiquette  has  too  long  held  them 
from  arraigning  the  medical  profession.  A  moment's  reflection  will 
show  that,  as  the  germs  may  not  manifest  their  presence  for  several 
days,  occasionally,  even  so  late  as  the  tenth  or  twelfth  day  after  birth, 
the  disease  may  reach  a  critical  condition  without  attracting  the  atten- 
tion of  any  one  competent  to  realize  the  danger  to  the  child's  eyesight, 
especially  where  the  doctor's  visits  are  infrequent,  or  the  accoucheur 
or  midwife  does  not  see  the  child  after  officiating  at  its  delivery. 

Who  is  responsible  for  the  ignorance  and  neglect  which  per- 
petuates this  needless  crippling  of  human  life  ?  It  is  clear  who  pays 
the  penalty — the  helpless  babies. 

Laws,  unless  enforced  by  an  enlightened  public  conscience,  do 
not  avail,  and  not  until  the  dawn  of  the  twentieth  century  have  the 
people  been  alive  to  public  health  measures.  To  Dr.  F.  P.  Lewis, 
for  many  years  president  of  the  Board  of  Trustees  of  the  New  York 
State  School,  at  Batavia,  and  chairman  of  the  New  York  State 
Commission  to  investigate  the  condition  of  the  blind  (1903-1906), 
came  the  inspiration  of  a  national,  and  possibly  international,  cam- 
paign for  the  prevention  of  blindness.  He  has  subsequently  blazed 
the  path  for  such  a  far-reaching  movement,  the  first  step  of  which 

2.  Section  288.  Unlawfully  omitting  to  provide  for  cliild.  A  person 
who     .     .     . 

3.  Being  a  midwife,  nurse  or  other  person  having  the  care  of  an  infant 
witliin  the  age  of  two  weeks  neglects  or  omits  to  report  immediately  to  the 
health  officer  or  to  a  legally  qualified  practitioner  of  medicine  of  the  city, 
town  or  place  where  such  child  is  being  cared  for,  the  fact  that  one  or 
both  eyes  of  such  infant  are  inflamed  or  reddened  whenever  such  shall  be 
the  case,  or  who  applies  any  remedy  therefor  without  advice,  or  except  by 
the  direction  of  such  officer  or  physician;  or 

4.  Neglects,  refuses  or  omits  to  comply  with  any  provision  of  this 
section  or  who  violates  the  provisions  of  such  license,  is  guilty  of  a  mis- 
demeanor. 

(522) 


Prevention  of  Infantile  Blindness  279 

was  taken  in  1906,  when  the  American  Medical  Association  ^  ap- 
pointed a  committee,  consisting  of  an  ophthalmologist,  an  obstet- 
rician and  a  sanitarian,  with  Doctor  Lewis  as  chairman,  "to  carry 
out,  through  the  associated  medical  organizations  of  the  nation, 
measures  for  the  prevention  and  control  of  birth  infections." 

The  above-named  committee,  in  their  report  to  the  House  of 
Delegates  of  the  American  Medical  Association,  in  1908,  which  was 
unanimously  approved  by  that  body,  and  also,  later,  by  the  Amer- 
ican Academy  of  Ophthalmology  and  Oto-Laryngology,  made  de- 
tailed recommendations,  which  may  be  summarized  as  follows : 

(i)  Require  registration  of  births;  licensed  midwives,  to  be 
under  control  of  board  of  health;  they  and  physicians  being  required 
to  report  each  case  of  disease. 

(2)  Let  boards  of  health  issue  circulars  of  instruction  to 
midwives  and  mothers. 

(3)  Let  health  boards  circulate  tubes  containing  prophylactic, 
with  directions  for  use. 

(4)  Insist  on  complete  records  in  all  hospitals  and  maternity 
institutions. 

(5)  Periodic  reports  by  all  physicians  on  all  cases  treated. 

(6)  Educate  the  public. 

(7)  Organize  the  medical  profession  throughout  the  country. 
(The    suggestions   have   reference   to   ophthalmia   neonatorum 

only.) 

The  state  committees  of  physicians  suggested  in  the  last  recom- 
mendation (No.  7)  were  appointed,  and  the  next  step  was  to  secure 
the  co-operation  of  a  national  lay  organization  to  promote  this  pre- 
ventive work.  Accordingly,  in  December,  1909,  the  chairman  of 
the  Committee  on  Ophtha#lra  Neonatorum  of  the  American  Medical 
Association  ®  applied  to  the  Russell  Sage  Foundation,  which  had,  in 
1908,  in  consequence  of  the  interest  aroused  by  the  New  York 
commission's  report  which  appeared  in  1907,  created  a  committee 
on  prevention  of  blindness,  with  Miss  Louisa  Lee  Schuyler  as 
chairman.  This  committee,  except  for  its  part  in  the  formation  of 
the  special  committee  now  working  under  the  auspices  of  the  New 

•  The  American  Medical  Association,  probably  the  strongest  professional 
society  in  the  country  has  a  membership  of  between  20,000  and  30,000  phy- 
sicians, and  through  its  organ,  the  "Journal,"  it  reaches  53,000  physicians. 

•This  committee  is  now  known  as  a  Committee  on  Prevention  of  Blind- 
ness. 

(523) 


28o  The  Annals  of  the  American  Academy 

York  Association  for  the  Blind,  and  organized  for  preventive  work 
in  the  State  of  New  York,  had  thus  far  remained  inactive,  but 
responded  at  once  to  Doctor  Lewis'  request,  appropriated  funds  and," 
later,  chose  an  able  secretary,  Samuel  Ely  Eliot,  with  headquarters 
at  105  East  Twenty-second  Street,  New  York  City.  Mr,  Eliot  is 
now  traveling  through  the  West,  organizing,  with  the  indorsement 
of  the  medical  profession,  co-operative  committees  for  the  prevention 
of  blindness  in  those  States  where  no  work  of  the  kind  exists. 

Previous  to  this  time,  and  acting  upon  a  suggestion  made  by 
Miss  Lucy  Wright,  the  general  superintendent  of  the  Massachusetts 
Commission  for  the  Blind,  the  Russell  Sage  Foundation  Committee, 
in  February,  1910,  called  a  conference  for  the  purpose  of  pooling  the 
information  and  experience  acquired  in  the  several  States  already 
carrying  on  preventive  work.  A  second  conference  was  held,  De- 
cember, 1910,  and  resulted  in  the  formation  of  a  national  association 
for  the  prevention  of  blindness  and  conservation  of  vision.  This 
body  invites  the  co-operation  of  societies  now  in  existence,  or  here- 
after formed,  for  advancing  the  welfare  of  the  blind;  for  the  pro- 
motion of  social  purity  and  sex  education;  for  preventing  infant 
mortality,  and  for  safeguarding  industrial  occupations.  In  addition, 
this  association  asks  the  aid  and  indorsement  of  state  and  national 
medical  societies,  of  the  National  Educational  Association  and  other 
educational  bodies,  of  the  public  and  private  schools  for  the  blind, 
of  commercial  bodies,  of  labor  organizations,  of  women's  clubs,  and 
of  all  the  other  organizations  dealing  with  social  and  economic 
problems  in: 

(i)     The  prevention  of  infantile  blindness. 

(2)  The  prevention  of  blindness  from  industrial  and  other 
accidents  and  from  disease.  ^B^ 

(3)  The  conservation  of  vision  through  improved  hygiene  dur- 
ing school  life,  and  in  industrial  occupations. 

Ophthalmia  neonatorum  as  a  cause  of  blindness  is  the  first 
to  be  attacked,  because  of  its  susceptibility  to  legislative  regulations. 
New  York  State,  as  has  been  mentioned,  has  a  special  committee 
and  executive  secretary  to  carry  on  this  work,  and  has  a  collection 
of  lantern  slides  and  photographs,  the  latter  of  which  have  been 
loaned  to  numerous  States  as  a  traveling  exhibit.^"     Massachusetts, 

^"Loan  Exhibit  and  lantern-slide  circular  of  Committee  on  Prevention 
of  Blindness,  New  York  Association  for  the  Blind. 

(524) 


Prevention  of  Infantile  Blindness  281 

under  the  direction  of  the  State  Commission,  employs  a  field  agent 
for  prevention  of  blindness  and  conservation  of  eyesight.^^  The 
unique  social  service  work  at  the  Massachusetts  Eye  and  Ear  In- 
firmary is  referred  to  later.  The  Ohio  Commission  has  conducted 
intensive  lecture  campaigns,  supplemented  with  extensive  news- 
paper stories  circulated  through  the  State  Press  Association.  Mary- 
land has  an  association  devoting  its  entire  attention  to  the  preven- 
tion of  blindness,  and  the  Pennsylvania  Association  for  the  Blind 
makes  work  for  prevention  one  of  its  important  activities. 

It  has  been  the  general  belief  that  the  midwives  were  the  most 
culpable  offenders  in  the  eye  disasters  of  infants.  In  most  of  our 
large  cities  and  elsewhere,  among  the  foreign-born  population,  a 
large  proportion  of  the  births  are  attended  by  these  women,  who, 
nine  times  out  of  ten,  are  incompetent  and  unclean.  The  1904 
records  in  Chicago  show  that  86  per  cent,  of  all  births  were  reported 
By  midwives,  and  in  New  York  City,  in  1907,  43.5  per  cent,  were  so 
reported.  The  investigations  of  Miss  Elizabeth  Crowell,  of  the  New 
York  Association  of  Neighborhood  Workers,  who  personally  visited 
five  hundred  midwives  in  their  homes,  brought  to  light  indescrib- 
able conditions  of  filth.  She  found  but  fifty  (one-tenth  of  the  whole 
number  interviewed)  who  could  be  qualified  as  capable  and  reliable. 

The  study  of  midwifery  presented  by  Miss  Carolyn  C.  Van 
Blarcom,  the  executive  secretary  of  the  Committee  on  Prevention  of 
Blindness  of  the  New  York  Association  for  the  Blind,  at  the  second 
Russell  Sage  conference,  followed  by  the  adoption  of  a  resolution 
presented  by  Dr.  William  N.  Studdiford,  of  the  New  York  City 
Board  of  Health,  to  the  effect  that  "this  conference  of  workers  for 
the  prevention  of  blindness  recommend  that  measures  be  taken  in 
this  country  to  secure  state  legislation  which  shall  provide  for  the 
training,  registration,  licensure,*^  supervision,  regulation  and  con- 
trol of  women  engaged  in  the  practice  of  midwifery,"  led  to  an  offer 
by  Dr.  John  Winters  Brannan,  president  of  the  Board  of  Trustees 
of  Bellevue  and  Allied  Hospitals,  of  New  York  City,  to  co-operate 
in  furnishing  the  first  training  for  midwives  in  this  country. 

While  the  midwives  have  probably  received  no  more  condemna- 
tion than  they  deserve,  the  general  practitioner,  too,  comes  in  for 
a  generous  indictment. 

"  See  articles  by  Henry  Copley  Greene,  in  "New  Boston." 
"The  license   should  not  be  regarded  as  a  diploma,  but  as  a  sanitary 
police  measure  maintained  by  the  board  of  public  health. 

(525) 


282  The  Annals  of  the  American  Academy 

A  unique  social-service  work,  introduced  at  private  expense  by 
Miss  Annette  P.  Rogers,  of  the  Massachusetts  Commission  for  the 
Blind,  and  now  a  part  of  the  regime  of  the  Massachusetts  Charitable 
Eye  and  Ear  Infirmary,^^  is  under  the  able  direction  of  Miss  Kath- 
arine Brannick,  who,  after  a  study  covering  three  consecutive  years, 
brought  to  light  the  startling  fact  that  of  a  total  of  275  carefully 
investigated  cases"  of  ophthalmia  neonatorum,  eight  births  only 
were  attended  by  midwives,  sixty-two  by  hospital,  dispensary,  and 
city  physicians,  and  205  by  private  practitioners !  Two  cases  in  one 
year,  in  the  practice  of  one  man,  in  which  both  babies  were  blinded ! 

Another  investigation  recently  made  in  Massachusetts,  under 
the  direction  of  the  Boston  School  for  Social  Workers,  disclosed 
the  fact  that  out  of  ninety-seven  doctors  visited,  with  large  obstet- 
rical practice,  "twenty-seven  always  used  a  prophylactic ;  forty,  sel- 
dom; twenty-eight  never  used  a  recognized  preventive,  although  the 
last  admitted  that  they  sometimes  employed  warm  water,  lemon  juice, 
citric  acid,  lard,  camomile  tea,  etc."  !  "Of  twenty-seven  cases  of 
ophthalmia  neonatorum  visited  by  nurses  in  the  summer  of  1909, 
under  the  direction  of  the  New  York  City  Department  of  Health, 
twenty-two  were  traced  to  physicians  and  five  to  midwives.  In 
thirty-three  cases  of  ophthalmia  neonatorum  investigated  by  a  field 
worker  in  the  New  York  School  of  Philanthropy  (1909-1910),  it 
was  found  that  twenty-two  cases  had  occurred  in  the  practice  of 
physicians  and  eleven  in  the  practice  of  midwives.  Only  one  of  the 
twenty-two  physicians  in  question  had  used  a  prophylactic  at  birth, 
while  three  of  the  eleven  midwives  employed  prophylaxis  as  a 
routine."  Of  5,949^^  births  in  five  Massachusetts  cities  in  1909,  only 
17  per  cent,  were  given  at  birth  any  preventive  treatment;  41  per 
cent,  were  attended  by  physicians  who  use  a  prophylactic  only  as 
their  judgment  dictates,  and  the  remaining  42  per  cent,  were  at- 
tended by  physicians  who  never  use  a  prophylactic  for  ophthalmia 
neonatorum. 

Such  facts  would  seem  to  argue  strongly  for  the  universal  use  of 
a  prophylactic,  for,  as  Doctor  Richardson  points  out,  "the  possibility 
of  any  baby  becoming  infected  at  the  time  of  confinement  should  be 

"  The  Massachusetts  Charitable  Rye  and  Kar  Infirmary  has  had  since 
1898  a  ward  devoted  to  the  care  of  ophthalmia  neonatorum. 

1*  Tliis  figure  does  not  represent  tlie  total  number  treated  at  the  Massa- 
chusetts Rye  and  Rar  Infirmary,  but  simply  those  investigated. 

"Sight  Saving  Bulletin  No.  7,  Massachusetts  Commission  for  the  Blind. 

(526) 


Prevention  of  Infantile  Blindness  283 

constantly  borne  in  mind,  and  it  is  desirable  to  carry  out  a  routine 
preventive  treatment  in  every  case." 

The  agitation  for  the  prevention  of  bUndness  carried  on  by 
commissions  and  other  bodies  organized  to  promote  the  interests 
of  the  blind  has  brought  to  light  the  Howe  law  in  several  States 
and  secured  its  enactment  in  others.  In  addition,  New  York,  Mass- 
achusetts, Ohio  and  Rhode  Island  provide,  through  their  state  boards 
of  health,  for  the  free  distribution  of  a  prophylactic.^"  While  not 
sufficiently  inclusive,  both  these  measures  are  of  value  not  only  in 
their  direct  results,  but  in  their  educational  bearing  on  the  question. 
The  latter  makes  easily  accessible  to  the  practitioner  the  means  of 
prevention  and  his  intelligence  and  conscience  force  him  to  use  them 
in  questionable  cases  at  least.  The  first  measure — -the  Howe  law, 
although  written  on  the  statute  books  of  seventeen  States,  has,  un- 
fortunately, been  enforced  in  a  few  localities  only.  Massachusetts 
has  one  of  the  best  of  these  revised  laws,  in  that  it  places  upon  the 
physician,  as  well  as  other  attendants,  the  responsibility  for  the 
report  of  the  infection.  Furthermore,  it  provides  that,  when  re- 
ported, the  board  of  health  shall  take  such  immediate  action  as  it 
may  deem  necessary,  in  order  that  blindness  may  be  prevented. 
Yet  in  1907- 1908 — two  years  after  the  law  was  passed — out  of  forty- 
six  investigated  cases,,  only  one  was  reported.  During  1909-1910,  in 
three  cases  resulting  in  blindness,  a  report  was  made  to  the  board 
of  health  by  the  attending  physician,  and  no  action  was  taken  by 
either  to  insure  proper  care !  The  excuse  often  given  for  failure  to 
report  cases  of  ophthalmia  neonatorum  is  that,  in  so  doing,  unpleasant 
reflections  may  be  cast  upon  the  parents.  The  Massachusetts  Com- 
mission's Bulletin  No.  3,  widely  distributed,  judiciously  points  out 
that  "gonorrhoea,  however,  is  not  necessarily  the  cause  of  these 
symptoms ;  and  as  the  law  wisely  deals  with  symptoms  only,  and 
not  with  diagnoses,  neither  nurses  nor  physicians  should  be  afraid 
that,  by  obeying  the  law,  they  will  put  any  stigma  on  the  child's 
family." 

But,  somehow,  in  some  way,  let  us  make  the  parents  realize 
that  their  blinded  child  is  a  disgrace  which  cannot  be  hidden.     Dr. 

>«  The  best  form  in  which  the  writer  has  seen  the  silver  nitrate  put 
up  is  a  small,  flat,  dark-colored  gelatin  capsule,  with  a  celluloid  cap,  which 
can  be  pierced  with  a  sterilized  needle.  These  small  receptacles  contain 
just  enough  for  one  application,  and  are  put  up  in  boxes  of  10  each. 
(Prepared   by   Schieffelin    &   Co.,   of  New   York.) 

(527) 


284  The  Annals  of  the  American  Academy 

Robert  L.  de  Normandie,  in  speaking  of  this  phase  of  the  subject, 
courageously  says:  "If  there  is  the  sHghtest  doubt  of  the  parents' 
character,  it  is  the  State's  duty  to  compel  the  infant's  health  to  be 
safeguarded  in  every  possible  manner." 

The  latest  word  from  Massachusetts  announces  the  prosecu- 
tion by  the  Boston  Board  of  Health  of  four  physicians  failing  to 
report  cases  of  inflammation  of  the  eyes  in  accordance  with  the  law. 
Three  were  convicted.  In  March,  1910,  the  conviction  and  fine  of  a 
midwife  in  Cleveland,  Ohio,  was  conducive  of  much  good  not  only 
in  revealing  the  power  of  the  law  to  the  woman's  confreres,  but 
in  the  wide  publicity  given  the  case  through  the  press.  Mothers  in 
distant  parts  of  the  State  appealed  to  the  authorities  for  aid  for 
their  babies'  "sore  eyes."  If,  by  prosecutions,  convictions  or  other 
means,  the  reporting  law  can  be  kept  before  the  public,  no  doubt 
much  good  will  be  accomplished. 

Workers  for  prevention,  however,  feel  that  the  root  of  the 
matter  is  not  yet  reached.  The  negligence  of  physicians  and  mid- 
wives  in  reporting  their  cases  of  birth  infection  has  brought  up  the 
whole  question  of  birth  registration,  which  is  most  inadequate  in 
the  United  States.  A  system  of  birth  registration  accounted  reli- 
able by  the  United  States  Census  Bureau  is  maintained  by  eighteen 
States  only.  This  so-called  registration  area  qovers  but  55  per  cent, 
of  the  population  of  the  United  States.  The  systems,  or,  rather, 
lack  of  systems,  in  the  rest  of  the  States  and  Territories  would  be 
difficult  to  match  in  any  other  civilized  country.  Most  of  the 
eighteen  States  referred  to  require  the  birth  certificate  to  be  sent  to 
the  Board  of  Health  within  ten  days.  Formerly,  when  records 
were  required  but  quarterly,  accumulations  of  birth  certificates  were 
sent  to  the  recorder  months  after  the  birth  of  the  child.  Even  now, 
with  the  ten-day  limit,  the  death  certificate  is  sometimes  received 
before  the  birth  is  officially  announced.  Pennsylvania  is  the  only 
State  within  our  knowledge  where  the  State  Health  Board's  staff 
includes  a  birth  registry  inspector.  This  man  is  a  field  officer  who 
investigates  doubtful  localities,  endeavors  to  compare  the  infant 
population  as  he  finds  it  with  the  neighboring  registry  office's  records. 
If  they  fail  to  check  up,  he  pursues  his  inquiries  to  locate  the  doctor 
or  other  attendant  who  omitted  to  send  in  the  birth  certificate.  It 
can  readily  be  understood  that  even  a  few  cases  probed  to  the  dis- 
covery of  the  delinquents  would  have  a  stimulating  eflFect  on  the 

(528) 


Prevention  of  Infantile  Blindness  285 

whole  neighborhood.  The  Health  Department  of  Pittsburg  now 
employs  such  an  inspector  for  that  city  alone. 

The  adoption  and  enforcement  in  every  State  of  a  ten-day 
limit  for  registration  of  births  would  be  a  distinct  step  in  advance, 
and  would  give  accurate  figures  for  the  compilation  of  statistics. 
If  this  requirement  were  coupled  with  a  law  making  the  use  of  a 
prophylactic  compulsory  and  universal,  ophthalmia  neonatorum  might 
soon  cease  to  handicap  our  race.  But  while  the  first  measure  seems 
reasonably  sure  of  materialization  in  the  near  future,  the  second 
seems  less  hopeful  of  achievement,  and,  as  has  already  been  shown, 
ophthalmia  neonatorum  may  claim  the  eyesight,  if  not  the  life,  of 
the  next  generation  long  before  the  expiration  of  the  ten  days! 

The  law  requiring  that  birth  infections  of  the  eyes  be  reported 
to  the  health  authorities  does  not  strike  deep  enough ;  at  best,  it  deals 
with  the  treatment  and  cure  of  the  disease.  We  are  committed  not 
only  to  labor  to  prevent  the  loss  of  sight,  but  also  to  prevent  the 
appearance  of  the  causal  disease.  The  free  distribution  of  a 
prophylactic  in  the  few  States  before  noted  is,  perhaps,  the  entering 
wedge  to  its  universal  use,  but  at  present  the  distribution  acts  prin- 
cipally in  an  educational  way.  How  can  we  more  effectively  prevent 
infection  without  making  compulsory  the  use  of  a  prophylactic? 

Two  substitute  measures  suggest  themselves: 

First,  earlier  registration  of  births;  e.  g.,  a  twenty-four  to 
thirty-six-hour  limit  for  the  receipt  of  the  record  at  the  office  of 
the  Board  of  Health,  This  plan  has  great  merit  in  that  the  ques- 
tions on  the  birth  certificate  may  be  in  themselves  a  reminder  of 
treatment  while  there  is  yet  time.  In  the  New  York  birth  report 
the  question  is  asked,  "Did  you  employ  a  preventive  for  ophthalmia 
neonatorum?  If  not,  why  not?"  In  Indiana  the  query  is  inserted, 
"Were  precautions  taken  against  ophthalmia  neonatorum?"  Now, 
that  health  officers  in  each  State  are  co-operating,  similar  questions 
will,  doubtless,  appear  on  the  birth  certificates  in  every  State  in  the 
Union.  With  this  early  registration  there  is  still  time  for  the  health 
authorities  to  send  to  the  physicians  and  midwives  warnings  such  as 
the  data  on  the  birth  certificate  demands.  New  York  has  secured 
a  reduction  in  the  time  limit  of  birth  registrations  from  ten  days 
to  thirty-six  hours.  This  law  obtains  throughout  the  State,  except- 
ing New  York  City,  Albany,  Brooklyn  and  Yonkers.  Some  physi- 
cians in  large  cities  where  such  reduction  in  time  has  been  proposed 

(529) 


286  The  Annals  of  the  American  Academy 

either  feel  themselves  competent  to  handle  the  matter  without  the 
interference  of  the  health  authorities,  or  are  so  overburdened  with 
their  daily  work  that  they  resent  the  additional  labor  involved  under 
the  twenty- four  to  thirty-six-hour  time  limit. 

To  meet  this  objection  on  the  part  of  the  busy  practitioner  and 
to  accomplish  practically  the  same  end,  a  second  suggestion  has  been 
made,  namely  that  the  accoucheur  should  send  to  the  health  author- 
ities a  notification  within  twenty-four  to  thirty-six  hours  of  the 
birth  of  a  child ;  such  notice  might  even  be  given  by  telephone.  Dr. 
Cressy  Wilbur,  at  the  recent  conference  in  New  York,  pointed  out 
the  value  of  such  a  proceeding,  and  made  it  clear  that  such  notifica- 
tion was  distinct  from  the  registration  containing  detailed  informa- 
tion, which  would  follow  within  ten  days.  The  warning  returned 
by  the  board  of  health  after  the  receipt  of  notification  could  not  be 
so  specific  as  that  which  could  be  given  after  the  receipt  of  the 
registration,  with  its  definite  question  regarding  ophthalmia  neona- 
torum, but,  as  it  is  hardly  possible  that  each  case  would  receive 
individual  inspection,  the  early  notification  would  serve  the  purpose 
of  early  registration,  in  one  respect;  namely,  to  get-the  fact  of  the 
occurrence  of  a  birth  to  the  authorities  promptly,  that  the  board  of 
health  may  expeditiously  point  out  the  danger  of  neglected  "sore 
eyes,"  and  call  attention,  likewise,  to  the  other  diseases  which  im- 
peril the  life  and  vitality  of  the  infant. 

But  doctors  object  to  being  made  responsible  for  the  handing 
in  of  two  certificates,  however  simple  the  first.  A  precedent  which 
might  be  followed  to  reach  an  equitable  solution  of  the  matter  is 
found  in  the  English  law,  of  August  28,  1907,  Chapter  XL,  which 
places  the  responsibility  for  the  early  notification,"  first,  upon  the 
father,  and  in  case  of  his  absence,  upon  the  attendant.  The  justice 
of  such  an  arrangement  is  self-evident.  The  primary  cause  of  the  dis- 
ease, in  the  large  majority  of  cases,  is  directly  traceable  to  the  father. 
The  parents,  not  Providence,  are  responsible  for  the  birth  of  the 
child,  and  also  for  the  transmission  of  diseases  which  make  the  gift 
of  life  not  a  blessing,  but  a  curse.  The  time  for  glossing  over  such 
facts  is  past.  In  our  indictment  for  criminal  carelessness  and 
ignorance  in  the  treatment  of  disease  we  must  surely  include,  with 
the  doctor  and  midwife,  the  parent. 

"The   suggested   24-hour   postcard   notification    is   not   a   substitute   for 
subsequent  registration. 

(530) 


Prevention  of  Infantile  Blindness  287 

In  addition  to  giving  the  fact  of  the  child's  birth  at  a  particular 
address,  the  notification  should  also  state  the  language  read  by 
the  family.  The  local  board  of  health  could  then  send  by  return 
mail  a  vividly  set  forth  circular  with  simple  statements  printed  in 
the  appropriate  language  and  calling  attention  to  the  symptoms  of 
ophthalmia  neonatorum  and  giving  a  warning  that,  without  prompt, 
expert  medical  care,  a  child  runs  the  risk  of  being  blind.  The 
early  notification  has  another  argument  in  its  favor,  for  the  same 
circular  which  serves  to  warn  against  ophthalmia  neonatorum  might 
also  caution  the  mothers  with  regard  to  two  other  diseases — puerperal, 
or  "child-birth,"  fever,  and  infection  of  the  mother's  breast,  which, 
while  not  endangering  the  eyesight  of  the  child,  deprive  him,  if  they 
go  unchecked,  of  his  best  source  of  nutrition,  thus  rendering  him 
less  able  to  withstand  the  encroachments  of  disease.  In  this  age 
of  conservation,  it  would  certainly  seem  as  if  our  future  citizens 
should  receive  as  much  protection  at  birth  as  is  given  them  when 
disease  has  developed.  Is  it  not  time  to  bring  the  knowledge  of 
such  diseases  out  into  the  open  and  beseech  the  aid  of  the  press,  the 
pulpit,  and  the  platform  in  attacking  them  vigorously?  Shall  not 
those  of  us  who  are  fathers  or  mothers  unite  to  protect  our  children 
from  these  insidious  foes?  The  enforcement  of  a  law  in  each  State 
isolating  syphilis  and  gonorrhoea  as  infectious  contagious  diseases 
would  mean  real  progress  in  the  prevention  of  blindness.  In  the 
meantime  let  us  not  deceive  ourselves.  It  is  not  alone  the  child 
,  known  to  have  vicious  surroundings  who  needs  to  be  rescued — all 
CHILDREN  need  to  be  safeguarded  by  intelligent  and  noble  teaching. 
The  policy  of  purity  through  ignorance  of  evil  is  no  longer  tenable. 
Innocence  of  evil  through  knowledge  purely  imparted  must  be  our 
slogan  for  the  future. 


(531) 


THE  WARFARE  AGAINST  INFANT  MORTALITY 


By  S.  W.  Newmayer,  M.D., 
In  charge  of  Child  Hygiene,  Department  of  Public  Health  and  Charities, 

Philadelphia. 


Health  is  fostered  by  legislation  and  education,  the  one  com- 
pelling and  the  other  prompting  us  to  seek  it.  The  citizens  of  a 
country  need  laws,  rules  and  regulations  to  assure  to  them  protec- 
tion, comfort,  happiness  and  health,  but  the  needs  of  the  child  are 
vastly  different  from  those  of  the  adult.  The  country  which  first 
recognizes  its  responsibilities  to  the  child,  and  tries  to  fulfil  those 
obligations  will  receive  the  recognition  of  the  world  as  being  the 
foremost  civilized  nation.  The  United  States  is  awakening  to  such 
realizations  when  it  contemplates  a  National  Child  Welfare  Bureau. 
Such  a  department  would  not  make  laws  to  correct  existing  evils 
and  defects,  but  it  could  collect  existing  data  on  the  care  of  the 
child,  study  the  most  practical  and  efficient  methods  for  its  welfare; 
codify,  simplify  and  place  to  their  full  and  proper  use  existing  laws. 
It  would  encourage  individual  investigations,  and  could  teach  state 
and  municipal  health  departments  and  children  organizations  how 
they  can  best  use  their  resources. 

There  is  little  sense  in  urging  an  increased  birth  rate  when 
we  do  not  know  how  to  keep  alive  and  healthy  those  children  born. 
Our  knowledge  of  food  values  and  rational  practical  infant  feeding 
is  vague.  Food  and  feeding  seem  too  commonplace  for  most  of 
our  scientists  to  devote  time  to.  Millions  of  dollars  are  given  for 
research  work  on  tuberculosis,  pellagra,  and  other  diseases  that 
have  been  much  advertised  but  are  far  less  destructive  to  our 
population  than  the  preventable  diseases  of  infancy.  While  the 
important  causative  factors  of  many  of  these  deaths  are  ignorance 
and  superstition,  improper  feeding  is  the  chief  one. 

The  least  read  volumes  published  are  health  reports.  This 
is  true  even  among  those  whose  duty  it  is  to  read  them.  Figures 
make  uninteresting  reading,  and  the  more  so  when  you  must  dig 
out  that  which  is  of  value.  A  study  of  the  Mortality  Statistics, 
Bureau  of  the  Census,  United  States,  1909,  answers  the  question, 

(532) 


The  Warfare  Against  Infant  Mortality  289 

why  we  should  be  aroused  to  activity.  A  total  of  140,057  babies 
under  the  age  of  one  year,  died  in  1909,  in  the  registration  area 
reported  upon  by  the  United  States  Census  Bureau.  This  area 
is  approximately  about  fifty-five  per  cent  of  the  population.  Of 
this  number  of  deaths,  the  diseases  of  early  infancy  claimed  33,274, 
including  premature  births  and  congenital  debility,  malformations 
7,286,  and  respiratory  diseases  22,990,  of  which  pneumonia  has 
17,549.  Tuberculosis  of  all  forms  claimed  2,406,  and  epidemic  dis- 
eases 7,132.  Convulsions,  which  means  no  correct  diagnosis  made, 
is  charged  with  4,613,  and  other  ill-defined  diseases  6,615.  Diar- 
rhea and  enteritis  tops  the  list  with  a  score  of  36,516,  while  other 
diseases  of  the  digestive  tract  adds  4,645. 

An  intelligent  comprehensive  study  of  these  statistics  is  neces- 
sary to  plan  our  lines  of  defense.  We  must  separate  those  diseases 
which  are  preventable  from  the  wholly  inevitable  ones.  Better 
and  more  accurate  statistics  are  needed,  especially  on  births.  Infant 
mortality  should  be  compared  to  infant  population  or  the  number 
of  births.  Full  accurate  statistics  are  at  present  not  available. 
Accurate  death  certificates,  recording  the  correct  cause  of  death 
would  lead  our  activities  in  the  right  direction.  While  some  of 
the  diseases  causing  infant  deaths  are  classified  as  non-preventable 
or  inevitable,  they  are,  to  a  varying  degree,  preventable.  The 
deaths  from  premature  births  and  congenital  debility  may  in  com- 
ing years  be  greatly  lessened  by  the  education  of  the  public  on 
such  questions  as  the  social  evil,  also  by  the  teaching  of  the  ex- 
pectant mother  and  placing  her  in  better  physical  and  hygienic 
conditions  to  meet  the  requirements  of  her  approaching  mother- 
hood. The  same  problems  that  are  to  be  considered  in  the  pre- 
mature births  and  the  deaths  of  earliest  infancy  are  important  for 
that  vast  unrecorded  number  of  infants  not  born.  The  fetus  which 
is  destroyed  after  the  time  of  viability,  the  loss  of  "the  possible 
infant"  is  not  only  adding  to  an  unregistered  infant  death  rate,  but 
also  making  the  mother  less  able  to  meet  the  needs  of  future  child 
bearing.  The  plea  that  these  earliest  deaths  are  fortunate  in  that 
they  give  us  the  "survival  of  the  fittest,"  is  erroneous.  That  we 
are  saving  and  prolonging  the  lives  of  a  lot  of  weaklings  is  true 
only  in  a  very  narrow  sense.  The  gardener  destroys  the  unde- 
sirable blooms  to  give  a  hardier  plant,  but  he  studies  how  to  obtain 
from  the  seed  only  the  best  and  strongest  plants. 

(533) 


290  The  Annals  of  the  American  Academy 

Respiratory  diseases,  among  which  pneumonia  is  the  arch  enemy, 
are  greatly  preventable  by  the  education  of  the  people  in  the  value 
of  fresh  air,  the  need  of  dressing  the  child  according  to  the  varia- 
tions of  temperature  and  humidity,  and  the  improving  of  the  hous- 
ing, sanitary  and  living  conditions.  Tuberculosis  and  epidemic  dis- 
eases are  to  a  great  extent  preventable,  while  diarrhea  and  enteritis, 
with  36,516  deaths  in  the  first  year  of  life,  is  almost  wholly  pre- 
ventable. This  is  the  disease  against  which  most  cities  have  directed 
their  energies.  Summing  up  the  deaths  at  all  ages  from  all  causes, 
we  find  that  one-fifth  of  these  deaths  are  among  infants  under  one 
year  of  age,  and  one-fourth  under  five  years.  Of  this  death  rate, 
one-half  die  in  the  first  six  months  of  life.  The  sad  feature  of 
this  record  is  one-half  of  these  deaths  among  infants  are  unneces- 
sary and  preventable.  The  inhabitants  of  the  United  States  are 
not  the  only  ones  who  have  this  perplexing  problem  to  solve,  for 
while  some  other  countries  are  more  fortunate,  others  are  less  so. 
Study  the  accompanying  statistics  from  the  various  countries  of 
a  civilized  world,  and  then  ask  if  some  urgent  action  is  not  neces- 
sary. In  one  year  a  grand  total  of  3,243,958  deaths  in  the  first 
year  of  life.  This  means  a  baby  dies  somewhere  every  ten  seconds, 
360  every  hour,  and  8,640  every  day ;  and  one-half  of  these  deaths 
are  preventable. 

Out  of  every  1,000  births,  the  following  number  of  children 
will  die  in  their  first  year  of  life  in  various  countries  forming  the 
civilized  world.     (Compiled  from  the  averages  of  ten  years.) 

Deaths  under  Deaths  under 

Cotuitry.  one  year  to  one  year  actu£il 

1,000  births.  numbers. 

Chili   326 30,303 

Russia  (European)    263  1,298,245 

Austria    222  200,553 

Roumania    218 49.589. 

Hungary    2ii   154.TOO 

German  Empire   197  374 153 

Jamaica    181   6.414 

Ceylon    179  23,255 

Spain    170 106,649 

United  States  (1900  approximated) . .  165  280,000 

Italy   161  83,970 

Belgium    154  28,499 

Japan    153  220,013 

(534) 


The  Warfare  Against  Infant  Mortality  291 

Deaths  under  Deaths  under 

Country.                                 one  year  to  one  year  actual 

1,000  births.  numbers. 

Servia    153  16,268 

France   148  1 15,378 

Bulgaria 144  22„S77 

Canada    140  8,200 

Great  Britain  and  Ireland   139  147,660 

Switzerland    138  11.441 

Holland   138  19,209 

Finland    133  10.877 

Western  Australia  127 756 

Denmark    124 8,089 

New  South  Wales  99 3,745 

Victoria   98  2,299 

Sweden 96 1,197 

Queensland    94 1,120 

Tasmania    93  433 

South  Australia   93  608 

Norway   86  4.231 

New  Zealand  76  2.233 


Grand  total 3243.958 

The  following  statistics  tell  most  graphically  what  the  chances 
are  for  any  one  at  a  certain  age,  to  live.  Note  that  the  infant  under 
one  year  has  the  same  chances  as  one  who  has  passed  the  biblical 
allotment  of  three  score  and  ten,  as  the  death  rate  at  these  periods 
are  about  the  same. 

Death  Rate  at  Each  Age  Period 

(U.  S.  Census,  1890-1900.) 

Death  Rate. 
1900.  1890. 

Under  one  year   165.4  205.8 

I  to    2  years    46-6  84.9 

5  to    9  years  5-2  7-3 

10  to  15  years  3-3  3-8 

25  to  30  years  8.6  9.9 

45  to  SO  years iS-2  16.5 

60  to  65  years   35  i  32-8 

70  to  75  years  75-2  64.5 

80  to  85  years  165.8  1446 

90  to  95  years  339-2  260.0 

95  and  over    418.0  347-1 

(535) 


292  The  Annals  of  the  American  Academy 

We  can  truly  believe  "the  business  of  being  a  baby  must  be 
classified  as  an  extra  hazardous  occupation."  We  have  sa  far 
focused  our  attentions  and  sympathies  upon  the  great  number  of 
deaths  among  infants,  but  how  about  the  living,  those  who  through 
ignorance  or  neglect  in  the  early  years  of  life,  in  that  great  import- 
ant formative  period,  the  time  of  building  the  foundation,  are  made 
to  swell  our  lists  of  weaklings  and  invalids,  to  fill  our  institutions 
and  hospitals.  "The  magnitude  of  the  loss  by  death  is  also  an 
index  to  the  amount  of  harm  inflicted  on  the  living."  Our  national 
forests  and  waterways  are  of  importance  and  claim  the  attention 
of  our  government,  but  we  must  not  forget  the  value  of  our  re- 
sources is  dependent  on  the  citizens  that  foster  them.  "The  child 
is  our  greatest  national  asset.    Let  conservation  begin  at  home." 

Several  countries,  for  years,  have  deplored  their  decreasing 
birth  rate.  Startling  statements  have  been  made  as  to  the  possible 
passing  of  certain  races.  They  watched  closely  the  coming  of  the 
race,  but  overlooked  the  going.  "It  is  not  the  babies  born,  but 
those  saved  that  count."  Governments  are  beginning  to  learn  from 
those  who  are  responsible  for  the  health  of  the  population  that 
"every  child  born  healthy  is  entitled  to  become  a  normal,  healthy  and 
useful  citizen." 

What  is  being  done  to  battle  with  the  mortality  among  infants .'' 
Ignorance,  neglect,  superstition  and  poverty  are  known  factors  of 
causation.  Pure,  clean  food  and  proper  feeding  are  necessary  for 
the  infant.  Statistics  prove  that  one  breast-fed  infant  dies  to  every 
ten  artificially  fed.  The  physician,  the  midwife  and  the  mother 
must  be  taught  the  necessity  of  breast  feeding.  The  child  must 
not  be  deprived  of  this  hereditary  right  on  the  least  pretext.  This 
need  was  forcibly  impressed  on  all  who  visited  the  exhibit  at  Bal- 
timore. Here  was  displayed  a  large  photograph  of  a  mother  with 
her  infant  at  the  breast  and  bore  the  inscription  "This  Baby  is 
getting  a  Square  Deal."  Is  yours?  Of  course  there  are  some 
cases  in  which  the  mother  is  unable  to  nurse  her  child.  Many  of 
these  would  have  had  the  necessary  nourishment  if  in  the  last 
stages  of  pregnancy  the  mother  had  been  taught  the  proper  hygiene 
of  this  period  and  if  she  had  the  proper  nourishment  for  herself. 
Philadelphia  has  succeeded  along  these  lines  through  the  visiting 
nurses  caring  for  expectant  women.  Where  poverty  existed  the 
mother  was  given  milk  free,  and  placed  in  the  best  hygienic  con- 

(536) 


The  Warfare  Against  Infant  Mortality  293 

dition.  If  she  was  compelled  to  work  in  a  factory  at  this  critical 
period,  one  of  the  charitable  organizations  was  appealed  to.  Igno- 
rance and  superstition  have  been  met  with  campaigns  of  educa- 
tion. Many  cities  in  this  country  employ  for  this  purpose  literature. 
Tons  of  circulars  and  pamphlets,  printed  in  all  languages,  have 
been  distributed  especially  in  the  congested  and  foreign  districts. 
It  is  questionable  if  these  accomplish  much  good. 

Attractive  posters  and  wall  cards,  with  instructions  for  mothers, 
have  been  successfully  used  in  several  cities,  including  Philadel- 
phia, New  York,  Chicago  and  Boston.  A  most  potent  means  of 
education  is  the  consultations  and  clinics,  especially  for  advising 
the  parents  of  well  infants.  These  have  been  copied  after  similar 
institutions  existing  for  years  in  France.  They  are  held  at  milk 
stations,  hospital  dispensaries,  schools,  and  in  open-air  tents  espe- 
cially constructed  for  this  purpose.  New  York,  Boston,  Cleveland, 
Rochester,  Chicago  and  Philadelphia  have  such  clinics  in  opera- 
tion. Much  of  their  success  depends  upon  having  physicians  and 
nurses  in  charge  who  are  interested  and  trained  in  this  par- 
ticular field  of  work.  Education  is  a  slow  process  and  all  the 
more  so  among  foreigners  handicapped  by  environment  and  super- 
stition. Results  are  obtained  by  utilizing  the  public  schools,  teach- 
ing the  older  girls  who  are  the  future  mothers.  These  girls  also 
succeed  in  carrying  home  sufficient  of  the  information  to  make  a 
decided  impression  on  their  parents.  Again  the  older  child,  espe- 
cially among  the  poor,  is  the  caretaker  of  her  younger  brothers 
and  sisters. 

The  most  valuable  weapon  against  infant  mortality  is  the 
trained  visiting  nurses  and  physicians,  who  enter  the  homes.  They 
observe  the  true  existing  conditions  and  apply  the  remedies  to 
the  defects.  They  teach  the  people  healthful  living  and  correct 
unsanitary  conditions.  They  prevent  illness  and  care  for  the  sick. 
To  keep  the  well  child  in  good  health  is  most  important,  but  we 
must  also  assure  proper  nursing  and  medical  care  to  the  sick  infant. 
The  wealthy  can  give  their  offspring  the  advantages  of  the  ser- 
vices of  specialists  and  trained  nurses,  while  the  poor  are  dependent 
on  the  dispensaries  and  hospitals.  An  investigation  during  the 
past  summer  in  Philadelphia  showed  the  hospitals  to  be  sadly 
inadequate  in  their  facilities  for  caring  for  the  sick  infants  of  the 

(537) 


294  The  Annals  of  the  American  Academy 

poor.  A  similar  investigation  in  other  large  cities  may  prove  aston- 
ishing. 

The  Department  of  Public  Health  and  Charities  of  Philadel- 
phia, under  its  director,  Dr.  Joseph  S.  Neff,  overcame  some  of 
this  deficiency  by  establishing  during  the  past  summer,  two  refuges 
for  babies  on  the  recreation  piers,  situated  on  the  river  front. 
Four  trained  nurses,  two  to  each  pier,  cared  for  the  sick  infants 
sent  there  by  the  nurses  visiting  the  homes  and  by  the  attending 
physicians.  These  stations  were  open  day  and  night,  were  prac- 
tically open-air  hospitals,  and  proved  one  of  the  most  successful 
undertakings  of  the  campaign. 

Pure,  clean  and  fresh  milk  is  an  absolute  necessity  to  conserve 
the  health  of  infants.  This  is  a  most  serious  problem  with  all 
cities.  The  magnitude  of  the  task  to  procure  a  supply  of  good 
milk  for  a  large  city  can  be  realized  from  the  following  facts:  The 
daily  milk  supply  of  Philadelphia  is  400,000  quarts,  and  an  annual 
of  146,000,000  quarts.  This  is  handled  by  3.000  milk  dealers  and 
5,000  producers,  scattered  in  four  different  states.  It  is  brought 
to  the  city  by  three  railroads,  a  trolley  company  and  innumerable 
wagons.  Chicago  requires  a  milk  supply  daily  of  almost  1,000,000 
quarts,  which  is  produced  on  12,000  farms,  by  120,000  cows.  This 
production  comes  from  five  states.  The  supply  for  New  York 
comes  from  35,000  farms,  located  in  six  different  states,  and  is 
shipped  from  700  dairies.  The  study  of  this  food  supply,  which 
is  one  of  the  gateways  to  success  in  reducing  infant  mortality, 
would  make  hundreds  of  volumes  of  literature.  Philadelphia  bids 
fair  to  reach  a  solution  of  the  problem  by  the  work  of  a  recently 
appointed  commission  on  milk.  This  commission  was  appointed 
by  the  mayor,  through  the  efforts  of  Director  Neff,  the  Bureau  of 
Municipal  Research,  and  others  interested  in  the  subject.  They 
are  studying  exhaustively  all  phases  of  the  situation.  One  thing 
is  evident,  that  milk,  when  received,  which  is  poor  in  quality  can 
never  be  made  suitable  food  for  infants,  and  the  best  milk  produced 
can  be  made  worthless  and  dangerous  when  improperly  handled  after 
it  leaves  the  producer.  This  neglect  or  ignorance  may  be  in  the  ship- 
ping, with  the  dealer,  or  at  the  home.  Lack  of  proper  refrigera- 
tion seems  to  be  a  crucial  point  in  most  of  the  troubles.  The  time 
must  come  when  cities  will  recognize  it  to  be  their  duty  to  estab- 

(538) 


The  Warfare  Against  Infant  Mortality  295 

lish  milk  stations  under  their  supervision,  to  supply  the  infant  popu- 
lation with  this  necessity  of  life. 

Milk  stations  to  supply  pure  clean  milk  for  infants  have  been 
maintained  in  a  number  of  American  cities.  This  milk  is  generally 
pasteurized  and  modified  to  suit  various  ages.  These  have  in  all 
cases  been  started  and  maintained  by  individuals  and  philanthropic 
organizations.  New  York's  recent  budget  appropriation  of  $40,000 
for  the  purpose  of  establishing  fifteen  infant  milk  depots  with 
equipment  and  machinery,  is  most  commendable  and  an  important 
step  in  the  right  direction.  There  is  no  doubt  that  a  city  owes  to 
the  health  of  its  infant  population  the  guarantee  of  pure,  clean 
milk,  and  this  is  the  most  practical  plan  to  obtain  it.  Philadelphia 
has  been  fortunate  in  possessing  an  institution  known  as  the  "Phil- 
adelphia Modified  Milk  Society,"  which  was  organized  in  1903 
through  one  of  its  enterprising  newspapers,  which  accepted  the  offer 
of  a  $5,000  plant  from  Mr.  Nathan  Straus,  of  New  York.  The 
society  has  been  maintained  and  steadily  increased  its  usefulness 
mainly  through  this  same  newspaper.  It  should  be  known,  however, 
that  at  no  time  did  they  use  the  project  as  an  advertisement.  During 
the  summer  of  1910  the  society  met  every  request  of  the  Health 
Bureau,  and  maintained  eighteen  distributing  stations,  including  one 
on  each  recreation  pier.  The  great  demand  for  such  a  commodity 
and  the  scope  of  the  work  can  be  realized  by  the  report  from  June 
I  to  December  31,  1910.  During  this  period  there  were  distributed 
760,847  bottles  of  modified  milk. 

To  best  cope  with  the  many  and  intricate  problems  arising 
to  reduce  infant  mortality  needs  a  division  or  bureau  under  the 
health  department,  especially  equipped  to  meet  the  needs  of  the 
child.  A  Bureau  of  Child  Hygiene  is  the  logical  outcome  of  these 
needs.  In  close  relation  to  infapt  mortality  is  the  licensing  and 
supervision  of  midwives,  lying-in  maternities,  and  homes  for  board- 
ing or  keeping  infants.  The  supervision  of  midwives,  controlling 
those  who  are  unfit  for  such  duties,  and  teaching  others  is  a  most 
important  duty.  One  can  realize  the  folly  of  overlooking  the  mid^ 
wife  as  a  factor  when  from  30  to  85  per  cent  of  the  deliveries  of 
infants  in  large  cities  are  in  the  hands  of  these  women.  This  custom 
of  employing  midwives  is  almost  universal  among  the  foreign  pop- 
ulation, and  exists  in  the  rural  districts  as  well  as  the  cities.  A 
study  of  this  work  in  Philadelphia  shows  that  the  intelligent  care 

(539) 


296  The  Annals  of  the  American  Academy 

of  the  infant  by  most  of  these  women  is  most  sadly  lacking.  Not 
only  does  it  contribute  to  the  mortality,  but  much  of  the  blindness 
among  infants  can  be  traced  to  their  neglect. 

A  concrete  illustration  of  what  can  be  accomplished  by  a  well- 
organized  and  practical  campaign  was  aflforded  by  Philadelphia  in 
the  summer  of  1910.  Dr.  Joseph  S.  Neff,  director  of  the  Depart- 
ment of  Public  Health  and  Charities,  reports  as  follows  on  the 
Philadelphia  experiment : 

As  a  result  of  the  provision  of  councils  for  the  employment  of  eight 
municipal  nurses  and  the  appropriation  of  moneys  for  general  expenses  in 
connection  therewith,  and  the  aid  rendered  by  various  private  associations  in 
the  summer  campaign  to  preserve  infant  life,  the  statistics  of  the  office  show 
that  during  the  past  summer  there  has  been  forty  per  cent  less  mortality  in 
infants  under  two  years  of  age  in  the  Second,  Third,  Fourth,  Fifth  and  Nine- 
teenth wards  where  efforts  were  concentrated,  as  compared  with  the  rest  of 
the  city.  The  entire  city  benefited  by  the  publicity  campaign,  the  erection  of 
new  milk  stations,  and  the  work  on  the  two  city  piers. 

Medical  inspectors  of  the  bureau  of  health  delivered  lectures  in  the 
spring  in  the  public  schools,  illustrated  by  paraphernalia  used  in  the  care  of 
the  baby,  applied  to  living  subjects  in  the  presence  of  the  older  girls  and  their 
parents.  Education  of  the  mother  was  continued  in  the  homes  by  personal 
instructions  and  demonstrations  by  the  nurses. 

Milk  Stations  Helped 

The  milk  stations,  too,  were  made  educational  centers  and  many  medi- 
cal clinics  were  established.  Exhibits  on  the  care  of  the  baby  were  most 
effective  teachers.  They  were  placed  in  milk  stations,  schools,  city  piers,  and 
other  institutions  and  consisted  of  graphic  charts,  display  cards,  photographs, 
sketches  and  models  which  depicted  the  proper  hygiene  and  care  of  the  infant. 

The  department  acknowledges  its  obligations  to  many  private  associa- 
tions for  their  co-operation  and  the  aid  rendered  in  this  movement.  The 
Philadelphia  Modified  Milk  Society  responded  to  our  every  request  to  open 
new  milk  stations^  which  they  did  in  eight  separate  instances  and  that  with- 
out cost  to  the  city.  The  Bureau  of  Municipal  Research  supplied  two  nurses 
and  one  clerk;  the  Visiting  Nurse  Society,  two  nurses;  the  Phipps  Institute, 
one  nurse;  Starr  Center,  two  nurses;  Baby  Alliance,  one  nurse;  the  Light- 
house, two  nurses,  all  of  whom  reported  directly  to  the  municipal  depart- 
ment having  this  campaign  in  charge,  and  worked  in  conjunction  with  the 
municipal  visiting  nurses. 

In  addition  there  were  several  private  activities  working  independently 
along  the  same  lines.  Qasses  of  mothers  were  held  once  a  week  in  several 
sections  and  prizes  were  given  by  the  Baby  Alliance  and  the  Lighthouse  to 
mothers  for  those  babies  showing  best  results.     Some  of  the  best  work  in 

(540) 


The  Warfare  Against  Infant  Mortality  297 

this  line  was  done  in  the  Twenty-second  and  Fifteenth  wards,  under  the 
charge  of  ladies  interested  in  the  movement. 

As  a  result  of  the  efforts  of  the  department,  through  newspaper  articles 
and  public  exhibits  of  soothing  syrups  and  babies'  comforters  containing 
opium  or  more  dangerous  drugs,  the  Philadelphia  Association  of  Retail 
Druggists  passed  resolutions  indorsing  the  position  of  the  department  and 
condemning  and  discouraging  the  sale  of  these  remedies  by  their  members. 
This  action  was  most  magnanimous  and  has  been  lived  up  to  by  the  druggists 
of  Philadelphia.  This  movement  has  been  far  reaching  as  it  was  reported 
by  the  Associated  Press  and  started  similar  movements  in  many  other  cities 
in  the  United  States. 

The  following  summary  gives  some  idea  of  the  amount  of  work  per- 
formed : 

Work  Performed  by  the  Visiting  Nurses 

Number  of  visits : 

Original  visits   for  investigation  and  instruction    9,528 

Special  nursing  visits   10,414 

Revisits    8,213 

Total  number  of  visits    28,155 

Number  of  sick  infants  given  nursing  care  5.043 

Number  of  expectant  women  instructed 745 

Disposal  of  cases : 

Referred  to  dispensaries  or  district  physicians   1,635 

Sent  to  hospitals  95 

Sent  to  country  or  seashore 53 

Cases  received  at  central  office: 

Number  of  calls  to  sick  infants  503 

Number  of  cases  of  destitution   71 

Number  of  cases  referred  to  various  organizations  134 

Number  of  deaths  among  cases  attended  by  nurses 26 

Work  Performed  at  Recreation  Piers 

Chestnut   Street,   opened  July   25;    Race   Street,   opened   August  3;  closed 
October  8: 

Number  of  sick  infants  in  attendance 2,434 

Number  of  well   infants   in   attendance    2,014 

Number  of  older  children  in  attendance 3,593 

Total  attendance  8,041 

Number  of  caretakers  instructed   2,681 

Bottles  of  modified  milk  dispensed  at  piers  13,449 

(541) 


298  The  Annals  of  the  American  Academy 

In  this,  as  in  other  medical  work,  the  needs  of  the  poor  can- 
not be  overlooked.  Besides  the  cases  of  destitution  referred  to  the 
various  charitable  organizations,  there  were  distributed  in  the  homes 
of  those  too  poor  to  pay  for  it  about  25,000  quarts  of  milk  and 
100,000  pounds  of  ice. 

A  study  of  its  causes  and  methods  of  prevention  of  the  enor- 
mous number  of  preventable  deaths  among  infants  most  clearly  shows 
that  the  work  is  not  for  any  one  class  of  people,  but  requires  the 
united  and  persistent  efforts  of  all,  health  authorities,  federal,  state 
and  municipal,  physicians,  teachers,  sociologists,  philanthropists 
and  every  one  who  has  at  heart  the  health,  happiness  and  prosperity 
of  the  nation. 


(542) 


/.'- 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 

on  the  date  to  which  renewed. 
Renewed  books  are  subject  to  immediate  recall. 


DECS    1969 


PEC  I7|tfe^ 

DFC  3     19697/ 


OCT  1  8  m? 


OCT  5     1972 


DEC  1119 
DFCi3'^q    REC. 


PI/BC 


SEMESTER  LOAN 


AUG  3  1  WA 


SUBJECT  TO  RECAL 

REC'DPUBl'^OV    «' 


91? 


LD  21-40m-5,'65 
(F4308sl0)476 


General  Library 

University  of  California 

Berkeley 


PUBLIC  HEALTH  LIBRAE 


